1. In this Assessment 1 Assignment, you will analyze an Episodic Note case study that describes abnormal findings in patients seen in a clinical setting. This is in a scholarly paper format and not SOAP format this week. 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. Follow the rubricâ€¦..Be sure to use APA formatâ€¦..and upload by Day 7.
Subjective:â€¢CC: â€œMy stomach hurts, I have diarrhea and nothing seems to help.â€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.â€¢PMH: HTN, Diabetes, hx of GI bleed 4 years ago â€¢Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhsâ€¢Allergies: NKDAâ€¢FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD â€¢Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:â€¢VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5â€™10â€; WT 248lbsâ€¢Heart: RRR, no murmursâ€¢Lungs: CTA, chest wall symmetricalâ€¢Skin: Intact without lesions, no urticaria â€¢Abd: soft, hyperactive bowel sounds, pos pain in the LLQâ€¢Diagnostics: None
Assessment:â€¢Left lower quadrant pain â€¢Gastroenteritis
PLAN: This section is not required for the assignment.
2. This week is the Midterm exam….due to be completed by Day 7. Please be mindful that when you sit down to take the examâ€¦.you will have exactly 2 hours and then the exam will shut down and submit.
3. You should continue to be practicing all of your assessment skills with your patient at home, and work in SH.