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?
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”.]