- 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 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.
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