Gastrointestinal Issue

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.
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 explain why with support of evidence based practice.
• 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?

******The assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed.
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.
Assessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests

SAMPLE SOLUTION

Episodic/Focus Note Template

Patient Information:
Initials: M.S, Age: 62, Sex: Female, Race: African American
S.
CC: Gastrointestinal Issue
HPI:
Location: Abdomen
Onset: 62-yearl old AA developed Crohn’s disease a month ago
Character: Too much inflammation of the digestive tract resulting in notable pain in the abdomen.
Associated signs and symptoms: the digestive tract is inflamed and the patient often has abdominal pain, extensive diarrhea, fatigue and loss in weight. The…