Medical Case Assessment: Treatment Guidelines

Medical Case Assessment: Treatment Guidelines

Differential Diagnoses

Crohn’s disease exacerbation is a severe chronic inflammatory issue in the human gastrointestinal tract that can affect all its parts from one’s anus to the oral cavity (Lemberg & Day, 2014). The examined woman said that she had been feeling pain in her abdomen intermittently. Also, she mentioned that she smoked approximately one package of cigarettes each day, which could lead to the development of the disease mentioned above.

Peptic ulcer disease presents a local defect of the stomach paries that slowly destroys the organ from the inside. To prove the diagnosis, it would be proper to mention that the patient reported having certain problems with her appetite that had decreased in recent weeks (Levine & Rubesin, 2017). Also, she was talking about diarrhea that bothered her along with the body temperature that was lower than usual.

Cholelithiasis fistula is a disease that has many manifestations and usually bothers biliary patients with the symptom of frequent colic (Agrawal, Joshi, & Manandhar, 2017).  The woman did not seem to suffer from the pain. However, it was obvious that it was severe (according to her unhappy mood and the sounds she was making because of the spasms). Medical Case Assessment: Treatment Guidelines.

Physical Examination Findings

As in every other case, some additional focus physical examination findings are necessary to prove or refute one of the differential diagnoses considered by a medical worker. To begin with, it is important to inspect the client’s abdomen to identify if there are any visual issues (Gomollón et al., 2016). This would be beneficial to understand whether or not she has some viruses or microorganisms that adversely impact inner organs. Another examination that has to be made is the identification of the pain’s location by palpating the patient’s abdomen area. Perhaps, the client does not know where exactly the epicenter of the pain she frequently feels is (Ha & Khalil, 2015). It may not be necessarily her stomach, but some other elements of her digestion system. Medical Case Assessment: Treatment Guidelines.Also, the auscultation session is necessary to reveal some details that can be found only with the help of a detailed interview.


Diagnostic Testing

As it is mentioned in the previous section of the paper, it is necessary to undergo both the computer tomography (CT) scan and a colonoscopy procedure test that can prove or refute the possibility of finding Crohn’s disease in the client’s body (Lemberg & Day, 2014). Such a diagnostic test as upper gastrointestinal endoscopy biopsy has to be completed to see where the problem is and the stage of its severity. Perhaps, the inflammation was not critical as the client started to feel the pain only two weeks ago (Ha & Khalil, 2015). Usually, the disease’s symptoms develop longer than that. Also, it is necessary to understand why the patient has a low-grade fever. Such symptoms as diarrhea and abdominal pains are supported by this issue.Medical Case Assessment: Treatment Guidelines.

Treatment Guidelines

If the diagnosis of Crohn’s disease is confirmed, the client will need to follow a certain diet that will be helpful for her digestion system. The diet will include fresh fruit and predominately vegetarian food with a variety of liquid soups (Cruz et al., 2015). Tylenol #3 can be used to reduce severe pains that may occur in the GI tract (Ha & Khalil, 2015). The patient has to consume only healthy food from now on with both vitamins C and B to unload the stomach from the tremendous burdens it experiences regularly (Bouguen et al., 2015). Indeed, it is also crucial to prescribing 5-ASA drugs to the patient to address the disease directly. The medicament will heal the inflammation and will make the process of digestion less painful (Ha & Khalil, 2015). The education of the patient includes knowledge in using all the prescribed medications and maintaining a healthy lifestyle (Pelser et al., 2014).Medical Case Assessment: Treatment Guidelines.


Agrawal, V., Joshi, U., & Manandhar, S. (2017). Spontaneous cholecystocolic fistula: An uncommon complication of chronic cholecystitis. Clinical Case Reports, 5(11), 1878-1881. Web.

Bouguen, G., Levesque, B. G., Feagan, B. G., Kavanaugh, A., Peyrin–Biroulet, L., Colombel, J.,… Sandborn, W. J. (2015). Treat to target: A proposed new paradigm for the management of Crohns disease. Clinical Gastroenterology and Hepatology, 13(6), 1042-1050. Web.

Cruz, P. D., Kamm, M. A., Hamilton, A. L., Ritchie, K. J., Krejany, E. O., Gorelik, A.,… Desmond, P. V. (2015). Crohns disease management after intestinal resection: A randomised trial. The Lancet, 385(9976), 1406-1417. Web.

Gomollón, F., Dignass, A., Annese, V., Tilg, H., Assche, G. V., Lindsay, J. O.,… Gionchetti, P. (2016). 3rd European evidence-based consensus on the diagnosis and management of Crohn’s disease 2016: Part 1: Diagnosis and medical management. Journal of Crohns and Colitis, 11(1), 3-25. Web.

Ha, F., & Khalil, H. (2015). Crohn’s disease: A clinical update. Therapeutic Advances in Gastroenterology, 8(6), 352-359

Lemberg, D. A., & Day, A. S. (2014). Crohn disease and ulcerative colitis in children: An update for 2014. Journal of Paediatrics and Child Health, 51(3), 266-270. Web.

Levine, M. S., & Rubesin, S. E. (2017). Diseases of the esophagus: A pattern approach. Abdominal Radiology, 42(9), 2199-2218. Web.

Pelser, C., Arem, H., Pfeiffer, R. M., Elena, J. W., Alfano, C. M., Hollenbeck, A. R., & Park, Y. (2014). Prediagnostic lifestyle factors and survival after colon and rectal cancer diagnosis in the National Institutes of Health (NIH)-AARP diet and health study. Cancer, 120(10), 1540-1547. Web. Medical Case Assessment: Treatment Guidelines.