Respiratory rate and depth normal Integumentary No rashes or abrasions noted

Respiratory rate and depth normal integumentary no

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and patient does not appear to be using accessory muscles to breath. Respiratory rate and depth normal.Integumentary: No rashes or abrasions notedReproductive: Labia clean without lesions and vaginal opening without discharge or foul odor. Upon palpation of ovaries no tenderness noted and both ovaries appear to be normalDiagnostic Testing Needed:
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ABDOMINAL ASSESSMENT 6CBC blood test: High white counts greater than 12,000 can show a potential infection or an acute inflammation accuring in the body.Complete Metabolic Panel blood test:Due to the patients frequent diarrhea she may have electrolic embalances that could pose further risks for the patient. Also, elevated creatinine and BUN levels can indicate harmful dehydration and kidney disfunction.HbA1c blood work:to distguinsh between the patients elevated BS level being a result of her current sickness or due to poor diabetes managementUrinalysis:tests the patient urine to see if urosepsis can be causing the increased abdominal painand boarderline fever.Abdominal Ultrasound: used to visualize how the abdominal organs functions. This can be used to rule out cholecystitis, ovarian cysts, uterian complications, flopian tube contorsion. CT abdomen: Used to rule out appendictis, hernias, diverticular disease, intestinal obstructions or abscesses. Pap test: This is a vaginal test that can rule out sexually transmitted diseases as a source for increased abdominal pain. Even though patient does admit to being faithful to her husband she also admits to no longer using condoms with him and not having an OB exam for 2 years. This test would be the last test performed if all above diagnostic test were normal due to the patients current marrital state. Possible Diagnoses 1. Gastroenteritis 2. Acute Appendicitis 3. Polynephritis 4. Colitis 5. Chron’s disease 6. STD
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ABDOMINAL ASSESSMENT 7 Acceptable Diagnoses Chron’s disease: is a disease that affects the bowl and is most common in caucasion usually in the second to third portion of this lifescale (Chastang, D.,2015). Many experience frequent diarrhea, abdominal pain, and weightloss. Patient will also have hyperactive bowel sounds and at times chron’s can be brought on by increased periods of stress in the patients life. Recommened diagnostic studies laboratory studies such as a CBC and BMP, stool testing, abdominal US and if those diagnostic testing come back positive then a sigmoidoscopy is recommended to visualize potential obstructions and formation of fistulas. (Chastang, D.,2015).
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  • Summer '15
  • Gastroenteritis, Footnote, Human abdomen

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