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Patient:
Abdominal Pain
Age:
45
Gender:
Female
Race:
African-American.
To
prepare:
·
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:
Assignment:
·
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?
·
Plan: What was your plan for diagnostics and primary
diagnosis? What was your plan for treatment and management, including
alternative therapies? Include pharmacologic and nonpharmacologic treatments,
alternative therapies, and follow-up parameters as well as a rationale for this
treatment and management plan.
·
Reflection notes: What would you do differently in a similar patient
evaluation?
Note: Your Focused Note Assignment must be signed by Day 7 of
Week 6.
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