EPISODIC VISIT: GASTROINTESTINAL

Work with a patient with a gastrointestinal condition that you examined during the last three weeks. You will complete your second Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, PMH, socioeconomic, cultural background, etc. In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes.

• Use the Episodic/Focused Note Template found in the Learning Resources for this week to complete this Assignment.
• Select a patient that you examined during the last three weeks based on any gastrointestinal conditions. With this patient in mind, address the following in a Focused Note:

• Subjective: What details did the patient provide regarding her personal and medical history?
• Objective: What observations did you make during the physical assessment?
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

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Sample Answer

 

 

 

Episodic/Focused Note

Patient: [Patient Initials/Identifier] Date of Encounter: [Date]

1. Subjective:

  • Chief Complaint (CC): [Patient’s primary reason for the visit – e.g., Abdominal pain, Diarrhea, Constipation, Heartburn]
  • History of Present Illness (HPI): [Detailed description of the CC: Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, Severity (OLDCARTS). Include any associated symptoms – e.g., nausea, vomiting, fever, blood in stool, weight loss.]
  • Past Medical History (PMH): [List any relevant past medical conditions – e.g., GERD, IBS, IBD, previous abdominal surgeries. If none, state “No relevant PMH”.]
  • Medications: [List all current medications, including over-the-counter and herbal supplements. Include dosages and frequency.]
  • Allergies: [List any allergies to medications, food, or environmental factors. If none, state “No known allergies”.]

Full Answer Section

 

 

 

 

  • Family History (FH): [List any relevant family history, particularly of gastrointestinal conditions – e.g., colon cancer, IBD.]
  • Social History (SH): [Include relevant social factors: Alcohol use, Tobacco use, Diet, Stress levels, Socioeconomic status, Cultural background (especially regarding food preferences and health beliefs).]
  • Review of Systems (ROS): [Briefly address other relevant systems: Constitutional, Cardiovascular, Respiratory, Genitourinary. Note any pertinent positives or negatives.]

2. Objective:

  • Vital Signs: [Temperature, Heart Rate, Blood Pressure, Respiratory Rate, Oxygen Saturation]
  • Physical Exam: [Detailed description of the abdominal exam: Inspection, Auscultation, Percussion, Palpation. Note any tenderness, masses, distension, bowel sounds. Also, include any relevant findings from other system exams – e.g., skin turgor for dehydration.]

3. Assessment:

  • Differential Diagnoses (in order of priority):
    1. [Most Likely Diagnosis – e.g., Acute Gastroenteritis] – [Brief rationale based on S&O]
    2. [Second Most Likely Diagnosis – e.g., Irritable Bowel Syndrome (IBS)] – [Brief rationale based on S&O]
    3. [Third Possible Diagnosis – e.g., Inflammatory Bowel Disease (IBD) – early stage] – [Brief rationale based on S&O]
  • Primary Diagnosis: [State your primary diagnosis – the most likely diagnosis based on the S&O. For example, “My primary diagnosis is Acute Gastroenteritis due to the patient’s acute onset of diarrhea, abdominal cramping, and vomiting, without any red flag symptoms like blood in stool or significant weight loss. The physical exam was consistent with this, showing diffuse abdominal tenderness but no signs of peritonitis.”]

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