Episodic Note Case Study
ABDOMINAL ASSESSMENT
Subjective:
CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
HPI: MT, 45 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.
PMH: HTN, Diabetes, hx of GI bleed 4 years ago
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units phs
Allergies: NKDA
FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
Diagnostics: None
Assessment:
Left lower quadrant pain
Gastroenteritis
Directions for assignment ( all aspects of instructions to be included).
1. Analyze the subjective portion of the note.
2. List additional information that should be included in the documentation.
3. Analyze the objective portion of the note.
4. List additional information that should be included in the documentation.
5. Is the assessment supported by the subjective and objective information? Why or why not?
6. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
7. Would you reject/accept the current diagnosis? Why or why not? Identify five possible conditions that may be considered as a differential diagnosis for this patient.
8. Explain your reasoning using at least four different references from current evidence-based literature.
9. Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
