Episodic Visit: Gastrointestinal Focused Note
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 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?
Note: Your Focused Note Assignment must be signed
Case
KZ 42 year female
9.30am Nursing staff call that has vomited x 2 yesterday and x 1 at 6am today PRN Zofron was administered mild relieved was noted. Nursing reported that pt has been grimacing and groaning and very restless all night. v/s 138/74 90 99.6 94% via trach collar RR 30. Reports decrease output for hershift. STAT Orders sent for MobileX CXray, abdomen Xray and BMP lab. Stop tube feed, Office appoint for 1pm
Hx MVA 22 year ago secondary to drus and ETOH, paraplegic, nonverbal, seizure, HTN, trach and peg, hypothyroid, vomiting, and constipation due to paralytic ileus, recurrent UTI chronic foley for retention
Lives at home with family with round the clock nursing care fromer smoker and ETOH
Meds : levothyroxine QD
Metoproplol BID
Prevacid solutab BID
Carbamazepine suspension BID
Colace solution BID
Senna BID
Nebs Q4 PRN
Afib
Miralax PRN constipation
Zofran ODT Q6PRN nausea
Tyl solution Q6 PRN pain
Allergies PCN
Tube feed Jevity 1.5 @75ml/hr with Q6 500ml fluids. Continuous
Office assessment 130/72 80 99.0 95% via trach collar RR 26
Skin intact
Abdomen distended and firm pt noted on palpation
Positive plus no edema
Lungs diminished at the bases and upper lobes rhonchi and wheezing noted
Floey observed with concentrated urine
CXray no infiltrates noted
Abdomen Xray result impacted stool in the descending colon
Dx constipation due to paralytic ileus
Treatment linzess BID x 3 days then daily , Fleet enema Qam x 3 days then Q weekly on Tuesdays
Continues current bowel regimen. Strict intake and ouput x 3 days .
Ensure free water flushed are administered.
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