List additional information that should be included in the documentation.

ABDOMINAL ASSESSMENT (Episodic Note Case Study)

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 510; 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

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?

6. -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 from the last 6 years.

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