Please follow directions carefully. I will attach some supportive resources for this assignment. 

You will analyze an Episodic note case study (listed below) that describes abnormal findings in patients seen in a clinical setting. WRITE THIS UP AS A NARRATIVE so that you are able to explain the analysis correctly. You will consider what history should be collected from the patients as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

Please DO NOT write this up in a soap note format.

You are NOT completing a soap note but analyzing all the information provided and discussing in your narrative what information is missing. You must consider all the information presented to determine what is missing. Please use your textbook guide to clinical documentation to help with this assignment. It will be a great source to use for this assignment as well as the required resources for this week.

ABDOMINAL ASSESSMENT

Abdominal Assessment

Subjective:

CC: “My stomach has been hurting for the past two days.”

HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain. 

PMH: HTN

Medications: Metoprolol 50mg

Allergies: NKDA

FH: HTN, Gerd,  Hyperlipidemia

Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female 

Objective:

• VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs
• Heart: RRR, no murmurs
• Lungs: CTA, chest wall symmetrical
• Skin: Intact without lesions, no urticaria
• Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound.
• Diagnostics: US and CTA
•  

Assessment:

1. Abdominal Aortic Aneurysm (AAA)
2. Perforated Ulcer
3. Pancreatitis

• With regard to the Episodic note case study provided:
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
•  

The Assignment

(In the past some students have listed each question that needs to be answered and then wrote their narrative under each question). This is easier for some students.

1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2.  
3. Analyze the objective portion of the note. List additional information that should be included in the documentation.
4.  
5. Is the assessment supported by the subjective and objective information? Why or why not?
6.  
7. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
8.  
9. Would you reject/accept the current diagnosis? Why or why not?
10.  
11.  Identify three possible conditions that may be considered as a differential diagnosis for this patient.
12.  
13.  Explain your reasoning using at least three different references from current evidence-based literature.