Episodic Note to Analyze

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

 

Episodic Note to Analyze

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
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Sample Solution

Section I: INTRODUCTION TO THE STUDY Introduction The country is encountering a basic deficiency of medical care suppliers, a lack that is supposed to increment in the following five years, similarly as the biggest populace in our country’s set of experiences arrives at the age when expanded clinical consideration is vital (Pike, 2002). Staffing of emergency clinics, facilities, and nursing homes is more basic than any time in recent memory as the huge quantities of ‘gen X-ers’ start to understand the requirement for more continuous clinical mediation and long haul care. Interest in turning into a medical caretaker has disappeared lately, likely because of the historical backdrop of the extraordinary and requesting instructive cycle, low compensation, firm and extended periods of time, and fast ‘wear out’ of those rehearsing in the calling (Wharrad, 2003). A complex oversaw care climate in this country is restricting the dollars accessible to be spent on nursing care. Numerous wellbeing callings, particularly

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