To determine the correct diagnosis, additional information from the patient can concern any food intolerance that she might have or has experienced. The nurse should also ask the patient whether she has endocrine disorders, takes laxatives, magnesium-based antacids, or whether she has ever been diagnosed with GI disorders (such as GERD, PUD, pyrosis, etc.) (Dunphy, Winland-Brown, Porter, & Thomas, 2015). This needs to be done to determine the primary diagnosis.
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Additional tests should rule out food intolerance (such as celiac disease); in this case, a blood test is necessary (Mayo Clinic, 2017). The sedimentation rate test can also be useful to determine whether there is any inflammation that was impossible to find during the physical exam. A stool test is necessary to rule out infections or inflammatory bowel disease.
The working diagnoses are as follows: food intolerance, inflammatory bowel disease, and irritable bowel syndrome. Food intolerance can be ruled out by a blood test. Furthermore, the patient does not link her complaints to the intake of specific foods (that can contain lactose, gluten, etc.). Inflammatory bowel disease (ulcerative colitis and Crohn’s disease) are also unlikely. UC is accompanied by colon bleeding, which would be found in the stool test, and watery diarrhea, which the patient did not confirm (Dunphy et al., 2015). The patient also denies tenesmus, which is typical for UC. Crohn’s disease is also characterized by bloody stool, fever, and weight loss (Dunphy et al., 2015). The test does not confirm blood in the stool, and the patient denies weight loss and fever. Irritable bowel syndrome is the primary diagnosis as it is characterized by abdominal pain relieved by defecation, change in stool appearance/frequency, and the feeling of urgency, which are all confirmed by the patient.
Lifestyle interventions (exercise, avoidance of specific food that triggers pain) and stress management are advised as necessary parts of the treatment plan (Johannesson, Ringström, Abrahamsson, & Sadik, 2015). An increase in physical activity can reduce the physical symptoms of IBS and improve the psychological state of patients. Dunphy et al. (2015) also recommend a high-fiber diet (20-30 g per day) and serotonin-receptor agonists or antagonists to affect or control constipation or diarrhea.
A follow-up is necessary if the patient’s symptoms worsen, the pain transforms or differs from that the patient is experiencing currently, or if the patient’s psychological or physical well-being deteriorates. The patient needs to be educated about the importance of stress avoidance, exercise, and correct medication use (e.g., that antidiarrheal medication should not be used for an extended period) (Dunphy et al., 2015). Health promotion can include mindfulness therapies to avoid stress and anxiety related to the disease, exercise to ensure that the patient does not have a sedentary lifestyle.
Wang and Yin (2015) point out that massage, acupuncture, and herbal medicine can be useful to patients with chronic constipation. These alternative therapies can be suggested, although it should also be noted that the effectiveness of acupuncture is debated. Herbal laxatives are also recommended as potential interventions.
If the patient feels anxious about her disease and the quality of life, she can join the circle of care to discuss the problem with other community members, including, for example, patients with similar issues or nurses. Support groups can help the patient understand that their quality of life and psychological well-being is not compromised by the illness.
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The code used for this visit is 99202 (problem-focused history, exam, and medical decision-making). According to EM University (2018), the Medicare reimbursement for this code is $75.73. There is a low level of severity.
Dunphy, L., Winland-Brown, J., Porter, B., Thomas, D. (2015). Primary care: The art and science of advanced practice nursing (4th ed). Philadelphia, PA: F.A. Davis Company.
EM University. (2018). Level 2 new patient office visit (99202). Web.
Johannesson, E., Ringström, G., Abrahamsson, H., & Sadik, R. (2015). Intervention to increase physical activity in irritable bowel syndrome shows long-term positive effects. World Journal of Gastroenterology: WJG, 21(2), 600-608.
Mayo Clinic. (2017). Celiac disease. Web.
Wang, X., & Yin, J. (2015). Complementary and alternative therapies for chronic constipation. Evidence-Based Complementary and Alternative Medicine, 2(1), 1-11.