EPISODIC VISIT: GASTROINTESTINAL

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."]

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".]