PRAC_6531 EPISODIC VISIT: GASTROINTESTINAL FOCUSED NOTE ESSAY

PRAC_6531 EPISODIC VISIT: GASTROINTESTINAL FOCUSED NOTE ESSAY

PRAC_6531 EPISODIC VISIT: GASTROINTESTINAL FOCUSED NOTE ESSAY

PRAC_6531 EPISODIC VISIT: GASTROINTESTINAL FOCUSED NOTE SAMPLE ESSAY

Patient Information:

Initials: H.N, Age: 65 years, Sex: Male, Race: White

S.

CC (chief complaint): “ I have been experiencing diarrhea.”

HPI: H.N. is a sixty-five-year-old white male patient who reported to the facility and was admitted to the hospital three weeks ago for pneumonia. The patient has been experiencing diarrhea for the last several days. The patient indicates that he has been experiencing loose and watery stools for the past few days. He also indicates that he has been experiencing lower abdomen cramping and bowel movements. He, however, indicates that there is no blood in the stool.

ORDER A PLAGIARISM-FREE PAPER HERE ON; PRAC_6531 EPISODIC VISIT: GASTROINTESTINAL FOCUSED NOTE ESSAY

Current Medications: The patient is currently using Zithromax for pneumonia (200 mg) and Lasix (60 mg PO once daily) for heart disease.

Allergies: The patient has no known allergies

PMHx: The patient’s necessary immunizations were taken as appropriate. He reports having been vaccinated fully for Covid-19 one year ago. The patient underwent a major surgery as a teenager, which was a corrective surgery for his right leg. The patient was diagnosed with congestive heart failure last year.

Soc Hx: The patient likes hiking and has been hiking actively since his early twenties. The patient is a former banker and also worked in chemical manufacturing until he retired some five years ago. The patient denies smoking tobacco. However, he occasionally drinks alcohol.

Fam Hx: The patient’s parents are both diseased. While the mother had diabetes and hypertension, the father had kidney failure and later heart disease. The patient is married and lives with his wife. They have three children who are all adults and live in separate cities.

ROS:

GENERAL: The patient reports feeling weak and tired. No unintended weight loss. No chills or fever.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No skin itches or rash.

CARDIOVASCULAR: No edema, no palpitations. No chest discomfort, chest pressure, or chest pain.

RESPIRATORY: No sputum, cough, or breath shortness.

GASTROINTESTINAL: Reports diarrhea and abdominal pain. No anorexia, nausea, or vomiting. No blood.

GENITOURINARY: No burning on urination

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria. Polydipsia reported. Decreased urine output.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Vital signs: BP 120/85, P 77, RR 18, Temp 97.9, O2 Sat 97% R/A.

Weight: 155.6 lbs Height: 5ft 2 inches BMI: 28.5

Physical exam: From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT: etc.).

General: The patient looks healthy, well-developed, and nourished. She seems bothered by the abdominal pain. She has no signs of acute distress.

HEENT: Head: Normocephalic/atraumatic. Symmetric. The hair pattern and distribution are normal. Eyes: PERRLA. EOMI. Conjunctiva pink. Sclera white. No drainage or redness was observed. Ears: No drainage observed; the external auditory canals are clear. The tympanic membrane is pearly gray and intact, with no bulging, retractions, redness, or fluid. Nose: No blockage or nose congestion. No discharge was observed. Throat: No lesions, moist and pink.

NECK: Supple. No neck stiffness or pain

Cardiovascular: Normal S1 and S2. Diastolic murmur observed

Pulmonary: No labored breathing; a symmetrical chest expansion was observed. No cough was reported. The lungs are bilaterally resonant and clear.

Gastrointestinal: No skin lesions or scars observed. A slight stomach distention, though non-tender. No abnormal sounds were heard. The bowel sounds were heard in all quadrants. No live or spleen enlargement

EXTREMITIES: No joint pain and tenderness, no edema. Motion range in extremities is normal, no deformities, normal gait.

NEUROLOGICAL: Alert and oriented, normal speech, normal muscle strength and tone. No focal, motor, or sensory deficits.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines).

A.

Differential Diagnoses (list a minimum of three differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

1. Acute renal failure: This is a condition where the kidneys do not filter waste from blood as it should be. A patient with this condition may present with various symptoms such as diarrhea, dehydration, seizures, chest pain or pressure, irregular heartbeat, weakness, nausea, fatigue, breath shortness, fluid retention, and, in some cases, decreased urine output (Pickkers et al.,2021). The patient showed some of the symptoms, making it a possible diagnosis. For example, diarrhea, dehydration, and decreased urine output were all shown by the patient. The patient is also at risk due to family history, making this a primary diagnosis.
2. Aortic valve regurgitation: This is another potential diagnosis. This is a condition where the aortic valve fails to close tightly, causing the blood to flow from the aorta to the left ventricle. Some of the symptoms include swollen feet and ankles, palpitations, chest tightness, discomfort or pain, fainting, irregular heartbeat, tiredness or weakness, and murmur. The patient also showed some of these symptoms. He was also diagnosed with congestive heart failure last year, making this a possible diagnosis.

• Bacterial Pneumonia: Bacterial pneumonia is a condition where the lungs are infected by bacteria. The most common symptom is a cough with productive sputum. Other symptoms include breath shortness, sharp chest pain, shaking chills, rapid pulse, low energy, loss of appetite, sweating, and fever (Talbot et al.,2019). Even though the patient showed some of these symptoms, he did not display the main symptom, which makes this diagnosis less likely

The patient has been referred to a cardiologist for better management of the heart condition. It is important to have therapeutic interventions for the remaining conditions. In the case of acute renal failure, the patient is already on Lasix. Therefore, the dosage can be adjusted to 40 mg IV every 12 hours (Rusnanta et al.,2021). As part of education, the patient needs to adhere to the medication schedule and be educated on the side effects. The patient should also develop a healthier lifestyle and stay away from alcohol. He also needs to use a balanced diet. In the case of pneumonia, the patient has been using Zithromax, which has been taking him well as the symptoms are going down. As such, the patient needs to continue with the current dosage before any adjustments are made later if there is a need to do so. The patient also needs to adhere to the medication schedule for better outcomes. As part of education, the patient should ensure that he is always hydrated by taking plenty of fluids.

Reflection: I agree with the preceptor’s treatment of the patient since it has been done based on the patient’s history and current symptoms. One of the aspects I learned from this case is that a gastrointestinal problem such as diarrhea can be experienced due to a primary underlying condition. For example, the diarrhea experienced by this patient was mainly due to renal complications. One of the things I would do differently is inquire from the patient about his history with kidney disease. I would also have referred the patient to a kidney specialist.

References

Pickkers, P., Darmon, M., Hoste, E., Joannidis, M., Legrand, M., Ostermann, M., … & Schetz, M. (2021). Acute kidney injury in the critically ill: an updated review on pathophysiology and management. Intensive Care Medicine, 47(8), 835-850. 10.1007/s00134-021-06454-7

Rusnanta, F., Tjahjono, C. T., Rahimah, A. F., & Martini, H. (2021). Right-Sided Heart Failure Presentation in Severe Valvular Aortic Stenosis: How to Deal with Diuretic Use?. Heart Science Journal, 2(1), 41-45. https://heartscience.ub.ac.id/index.php/heartscience/article/view/159

Talbot, G. H., Das, A., Cush, S., Dane, A., Wible, M., Echols, R., … & Foundation for the National Institutes of Health Biomarkers Consortium HABP/VABP Project Team. (2019). Evidence-based study design for hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia. The Journal of Infectious Diseases, 219(10), 1536–1544. https://doi.org/10.1093/infdis/jiy578

Unger, P., & Tribouilloy, C. (2020). Aortic stenosis with other concomitant valvular disease: aortic regurgitation, mitral regurgitation, mitral stenosis, or tricuspid regurgitation. Cardiology Clinics, 38(1), 33-46. https://doi.org/10.1016/j.ccl.2019.09.002

BUY A CUSTOM PAPER HERE ON; PRAC_6531 EPISODIC VISIT: GASTROINTESTINAL FOCUSED NOTE ESSAY

For this Assignment, you will 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.

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?
• Patient information: Additional info can be made up
  

  Client Information	Site	Office
  	Age	65+ years
  	Gender	Male
  Visit Information	Student Level of Function	Intense supervision – Level 1
  	Category of Care	Direct Patient Care
  Practice Management	Type of visit/phys. exam	New acute visit – 99203
  Diagnosis	2 All valve disease
  	1 Acute renal failure
  	3 Pneumonia all types
  Student Notes	This is a new patient visit. The patient was admitted to the hospital 3 weeks ago for pneumonia. The patient has been experiencing diarrhea for the last several days. The patient was diagnosed with congestive heart failure last year. The patient was previously being seen by the VA and wants a primary care doctor. Upon examination, breath sounds bilaterally equal and clear. The patient was given a referral to cardiology.

BUY A CUSTOM PAPER HERE ON; PRAC_6531 EPISODIC VISIT: GASTROINTESTINAL FOCUSED NOTE ESSAY

Criteria

Ratings

Pts

Organization of Write-up

30 to >26.0 pts Excellent

26 to >23.0 pts Good

23 to >20.0 pts Fair

20 to >0 pts Poor

All information organized in logical sequence; follows acceptable format

Information generally organized in logical sequence; follows acceptable format

Errors in format; information intermittently organized

Errors in format; information disorganized

30 pts

Thoroughness of History

20 to >17.0 pts Excellent

17 to >15.0 pts Good

15 to >13.0 pts Fair

13 to >0 pts Poor

Thoroughly documents all pertinent history components for type of note; includes critical as well as supportive information

Documents most pertinent history components; includes critical information

Fails to document most pertinent history components; Lacks some critical information or rambling in history

Minimal history; critical information missing

20 pts

Thoroughness of Physical Exam

10 to >8.0 pts Excellent

8 to >7.0 pts Good

7 to >6.0 pts Fair

6 to >0 pts Poor

Thoroughly documents all pertinent examination components for type of note

Documents most pertinent examination components

Documents some pertinent examination components

Physical examination cursory; misses several pertinent components

10 pts

Diagnostic Reasoning

10 to >8.0 pts Excellent

8 to >7.0 pts Good

7 to >6.0 pts Fair

6 to >0 pts Poor

Assessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests

Assessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems.

Assessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests

Assessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests

10 pts

Treatment Plan/Patient Education

10 to >8.0 pts Excellent

8 to >7.0 pts Good

7 to >6.0 pts Fair

6 to >0 pts Poor

Treatment plan and patient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Evidence based decisions. Cost effective treatment. Reflection is thoughtful and in depth.

Treatment plan and patient education addresses most issues raised by diagnoses. Reflection is thoughtful and in depth.

Treatment plan and patient education fail to address most issues raised by diagnoses……………………………………….. Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently.

Minimal treatment plan and/or patient education addressed … Reflection is absent.

10 pts

Written Expression and FormattingEnglish writing standards: Correct grammar, mechanics, and proper punctuation.

10 to >8.0 pts Excellent Uses correct grammar, spelling, and punctuation with no errors.

8 to >7.0 pts Good Contains a few (1-2) grammar, spelling, and punctuation errors.

7 to >6.0 pts Fair Contains several (3-4) grammar, spelling, and punctuation errors.

6 to >0 pts Poor Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

10 pts

Criteria	Ratings							Pts
Written Expression and FormattingThe assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed.	10 to >8.0 pts Excellent Contains parenthetical/in-text citations and at least 3 evidenced based references are listed.		8 to >7.0 pts Good Contains parenthetical/in-text citations and at least 2 evidenced based references are listed		7 to >6.0 pts Fair Contains parenthetical/in-text citations and at least 1 evidenced based reference is listed		6 to >0 pts Poor Contains no parenthetical/in- text citations and 0 evidenced based references listed.	10 pts
Total Points: 1