Review the Episodic note case study your instructor provides you for this weekââ¬â¢s Assignment. Please see the ââ¬ÅCourse Announcementsââ¬Â section of the classroom for your Episodic note case study.
With regard to the Episodic note case study provided:
Review this weekââ¬â¢s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patientââ¬â¢s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Assignment
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.ABDOMINAL ASSESSMENT
Subjective:
ââ¬Â¢ CC: ââ¬ÅMy stomach hurts, I have diarrhea and nothing seems to help.ââ¬Â
ââ¬Â¢ HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
ââ¬Â¢ PMH: HTN, Diabetes, hx of GI bleed 4 years ago
ââ¬Â¢ Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
ââ¬Â¢ Allergies: NKDA
ââ¬Â¢ FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
ââ¬Â¢ Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
ââ¬Â¢ VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5ââ¬â¢10ââ¬Â; WT 248lbs
ââ¬Â¢ Heart: RRR, no murmurs
ââ¬Â¢ Lungs: CTA, chest wall symmetrical
ââ¬Â¢ Skin: Intact without lesions, no urticaria
ââ¬Â¢ Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
ââ¬Â¢ Diagnostics: ?
Assessment:
ââ¬Â¢ Left lower quadrant pain
ââ¬Â¢ Gastroenteritis
Review the Episodic note case study your instructor provides you for this weekââ¬â¢s
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