Patient with abdominal pains, Use the template attached below. 3 APA References .

 Master of Science in Nursing   PRAC 6531:  Primary Care of Adults Across the Lifespan Practicum

Episodic/Focus Note Template

Patient Information:

Initials, Age, Sex, Race


S.

CC (chief complaint) a BRIEF statement identifying why the patient is here in the patient’s own words (e.g., “headache,” NOT “bad headache for 3 days”).

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (i.e., previous and current use), any other pertinent data. Always add some health promo question here (e.g., whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system).

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.


O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e., General: Head: EENT: etc.).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).


A

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Differential Diagnoses (list a minimum of three differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.


P.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

You are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

© 2020 Walden University 1

Chief Complaint: abdominal pain History of Present Illness: Ms. Sonita___ is a 46 year old African American female with Crohn’s Disease, DM, and HTN who presented to the ED after two days of severe abdominal pain, nausea, vomiting, and diarrhea. She stated that on Wednesday evening after being in her usual state of health she began to experience sharp lower abdominal pain that radiated throughout all four quadrants. The pain waxed and waned and was about a 4/10 and more intense than the chronic abdominal pain episodes she experiences periodically from her Crohn’s disease. The pain was sudden and she did not take any medications to alleviate the discomfort. The abdominal pain was quickly followed by two episodes of partial diarrhea and soft stool that was tan in color with no signs of blood. Her abdominal pain continued and she developed nausea and then vomited six times that evening before going to sleep. Overnight her abdominal pain worsened and she stayed in bed for most of the day on Thursday. She had nausea again all day but had no other episodes of diarrhea or vomiting that day and did not eat anything for fear of vomiting. She was able to drink water and keep it down. By late Thursday night, her pain had intensified to a 10/10 and she called 911 and was brought to the ER by ambulance from her home in Washington DC