Chat with us, powered by LiveChat 1. Analyze the subjective portion of the note. List additional information that should be include | Max paper
  

  

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 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.

You will analyze an Episodic note case study (listed below) that describes abnormal findings in patients seen in a clinical setting. WRITE THIS UP AS A NARRATIVE so that you are able to correctly explain the analysis. 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.

Please DO NOT write this up in a soap note format.

You are NOT completing a soap note but analyzing all the information provided and discussing in your narrative what information is missing. You need to take all of the information presented into consideration to determine what is missing. Then you what consider and what is normally documented in the soap note for the various parts of the note. Please use your textbook guide to clinical documentation to help with this assignment. It will be a great source to use for this assignment as well as the required resources for this week.

 

ABDOMINAL ASSESSMENT

Abdominal Assessment

SUBJECTIVE:


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

· With regard to the Episodic note case study provided:

. Review this week’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 patient’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

(In the past some students have listed each question that needs to be answered and then wrote there narrative under each question). This is easier for some students.

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 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.

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