Episodic Note Case Study

ABDOMINAL ASSESSMENT

Subjective:

CC: “My stomach hurts, I have diarrhea and nothing seems to help.”

HPI: MT, 45 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.

PMH: HTN, Diabetes, hx of GI bleed 4 years ago

Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units phs

Allergies: NKDA

FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD

Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs

Heart: RRR, no murmurs

Lungs: CTA, chest wall symmetrical

Skin: Intact without lesions, no urticaria

Abd: soft, hyperactive bowel sounds, pos pain in the LLQ

Diagnostics: None

Assessment:

Left lower quadrant pain

Gastroenteritis

Directions for assignment ( all aspects of instructions to be included).

1. Analyze the subjective portion of the note.

2. List additional information that should be included in the documentation.

3. Analyze the objective portion of the note.

4. List additional information that should be included in the documentation.

5. Is the assessment supported by the subjective and objective information? Why or why not?

6. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

7. Would you reject/accept the current diagnosis? Why or why not? Identify five possible conditions that may be considered as a differential diagnosis for this patient.

8. Explain your reasoning using at least four different references from current evidence-based literature.

9. Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Consider the following scenario:
You are a charge nurse and one of your direct subordinates is also a personal friend of yours. You have noticed a decline in her/his professional performance as witnessed by tardiness, delayed patient response, failing to complete documentation, and altered peer relationships.
By Day 3 of Week 8 (Post First)
Explain how you would mentor and coach the subordinate nurse in the scenario. Specifically address the following:

Explain your expectations of the performance the nurse should be demonstrating.
Explain the type of feedback you would provide to the nurse. Be specific and provide examples grounded in the Resources on coaching and mentoring.
Explain how the AONL Competencies on Leadership and Professionalism and the ANA Magnet Standard on peer feedback support would inform your feedback choices.

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.

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