What details did the patient provide regarding her personal and medical history?

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?
• My Patient Is a 15 y/o M with a cc of chronic fatigue and “sharp abd pain in the left upper quad intermittently x 2 weeks. NKDA, no previous med hx.
• Appears tired but AOx4 presented with his father.
Increased sounds over liver with percussion
Diff dx:
1) Mono
2) COVID
3) ?
4) ?
5) ?
*** MUST be reason to explain away or confirm diagnosis. Confirm Mono please.
Plan of treatment including medication with doses
Will send template to use- needs a physical assessment

SAMPLE SOLUTION

Patient Information
Patient initials: J.D
Age: 15 years
Gender: Male
Race: Hispanic
S
Chief Complaint (C.C): Complains of chronic fatigue and sharp pain in the left upper quad intermittently.
History of patient illness (HPI): J.D is a 15-year-old Hispanic male who reports to the clinic with the chief complaint of chronic fatigue and sharp abdominal pain in the left upper quad intermittently. The symptoms have been present for two weeks now.
Current medications: The patient is not on any medications
Allergies: No known drug allergies (NKDA).
Past medical history (PMHx): The patient has no past medical…