Homework
Subjective:
o CC: "My stomach hurts, I have diarrhea and nothing seems to help."
o 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.
o PMH: HTN, Diabetes, hx of GI bleed 4 years ago
o Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
o Allergies: NKDA
o FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
o Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
o VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5'10"; WT 248lbs
o Heart: RRR, no murmurs
o Lungs: CTA, chest wall symmetrical
o Skin: Intact without lesions, no urticaria
o Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
o Diagnostics: None
Assessment:
o Left lower quadrant pain
o Gastroenteritis
Task
a. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
b. Analyze the objective portion of the note. List additional information that should be included in the documentation.
c. Is the assessment supported by the subjective and objective information? Why or why not?
d. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
e. 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.
Format your homework according to the give formatting requirements:
a. The answer must be double spaced, typed, using Times New Roman font (size 12), with one-inch margins on all sides.
b. The response also includes a cover page containing the title of the homework, the course title, the student's name, and the date. The cover page is not included in the required page length.
c. Also include a reference page. The references and Citations should follow APA format. The reference page is not included in the required page length.