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 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:
