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Original Question
Evaluate Outcomes Review the electronic health record and answer the question that follows. History & Physical Laboratory Results Date/Time History & Physical 04/01/20XX 1420 Client: Tia Johnson (pronouns she/her/hers), 13 years old​ Chief Complaint: Severe abdominal pain and weakness​ History of Present Illness: Tia presents to the emergency department (ED) with complaints of sudden and severe abdominal pain and weakness. According to the client and her accompanying family member, the pain started abruptly and is concentrated in the abdominal area. The family reports a history of sickle cell disease, and they express concern that the current symptoms may be related to the condition. The pain is described as sharp and has been progressively worsening over the past few hours.​ Medical History: Known history of sickle cell disease. No recent blood transfusions. No recent illnesses or infections reported. ​ Vital Signs: Blood pressure 88/60 mmHg, heart rate 110 bpm, respiratory rate 18 bpm, temperature 98.6 °F (37 °C) oral, pulse oximetry 90% on room air​ General Appearance: Appears uncomfortable and in distress​ Abdomen: Tenderness on palpation, particularly in the left upper quadrant. No rebound tenderness. Abdomen appears slightly distended.​ Skin: Slight pallor noted.​ Respiratory: Clear breath sounds bilaterally. The nurse practitioner monitors the client’s condition.
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