The Assignment

1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
3. Is the assessment supported by the subjective and objective information? Why or why not?
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5. Would you reject/accept the current diagnosis? Why or why not? Identify five 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.

In this Assessment 1 Assignment:

 

You will analyze an Episodic Note case study that describes abnormal findings in patients seen in a clinical setting. 

 

You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. 

 

You will also formulate a differential diagnosis with several possible conditions.

Review the following Episodic note case study for this Assignment: See Below

 

Assessment of the Abdomen and

Gastrointestinal System

 

ABDOMINAL ASSESSMENT:

 

Subjective:

• CC: “My stomach hurts, I have diarrhea and nothing seems to help.”

• 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.

• PMH: HTN, Diabetes, hx of GI bleed 4 years ago

• Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10

units qhs

• Allergies: NKDA

• FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN,

Hyperlipidemia, GERD

• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

• VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs

• Heart: RRR, no murmurs

• Lungs: CTA, chest wall symmetrical

• Skin: Intact without lesions, no urticaria

• Abd: soft, hyperactive bowel sounds, pos pain in the LLQ

• Diagnostics: None

Assessment:

• Left lower quadrant pain

• Gastroenteritis

PLAN: