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.
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 PPIâ€™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.
Medications: Metoprolol 50mg
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
(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.
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