Skip to ContentGo to accessibility pageKeyboard shortcuts menu
OpenStax Logo

Read the Electronic Health Record

1.
Possible considerations: the elevated WBC and CRP levels indicate an inflammatory or infectious process, which is concerning, given the patient's history of diverticular disease. The increased abdominal pain and fever are also worrying signs.
2.
The most concerning information is the elevated WBC count and CRP levels, combined with the findings from the CT scan indicating acute diverticulitis with pericolonic fat stranding. This suggests a significant inflammatory process that could lead to complications if not promptly managed.
3.
An expected finding is the presence of inflamed diverticula in the sigmoid colon, because the patient has a known history of diverticular disease. The mild fever and elevated inflammatory markers (WBC and CRP) are also expected in the context of acute diverticulitis.
4.
It is important to question if the patient has any history of allergic reactions to the prescribed antibiotics (ciprofloxacin and metronidazole). Additionally, considering the patient’s decreased appetite and occasional nausea, it may be necessary to assess for any potential adverse reactions to the medications or need for adjustments in pain management. Furthermore, questioning the adequacy of the current antibiotic regimen and considering the need for IV antibiotics or hospitalization should be discussed with the health-care team.
Citation/Attribution

This book may not be used in the training of large language models or otherwise be ingested into large language models or generative AI offerings without OpenStax's permission.

Want to cite, share, or modify this book? This book uses the Creative Commons Attribution License and you must attribute OpenStax.

Attribution information
  • If you are redistributing all or part of this book in a print format, then you must include on every physical page the following attribution:
    Access for free at https://openstax.org/books/medical-surgical-nursing/pages/1-introduction
  • If you are redistributing all or part of this book in a digital format, then you must include on every digital page view the following attribution:
    Access for free at https://openstax.org/books/medical-surgical-nursing/pages/1-introduction
Citation information

© Sep 20, 2024 OpenStax. Textbook content produced by OpenStax is licensed under a Creative Commons Attribution License . The OpenStax name, OpenStax logo, OpenStax book covers, OpenStax CNX name, and OpenStax CNX logo are not subject to the Creative Commons license and may not be reproduced without the prior and express written consent of Rice University.