Evaluation and Management of Gastrointestinal Disorders Coursework

please use the template attached for this assignment
please you can use age group 20-65 years old please.
thank you.

Episodic/Focused SOAP Note Template

Please use this template for this Assignment thank you

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 - for instance "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 ie angioedema, anaphylaxis, etc. 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 (previous and current use), any other pertinent data. Always add some health promo question here - such as 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.

Differential Diagnoses (list a minimum of 3 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.  

Include additional laboratory and diagnostic tests, consults, therapeutic modalities, health promotion patient education as well as disposition/follow up instructions as they pertain to your patients’ assessment

________________________

Preceptor Signature and Date

Signature is REQUIRED for this assignment.

· Preceptor must sign all SOAP notes before submission. Any SOAP note not including the preceptor signature will not be graded, or will be graded as a late submission if necessary.

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 6^th edition formatting.

Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.

• Part 12, “Evaluation and Management of Gastrointestinal Disorders” (pp. 623-730)

This part examines the pathophysiology and clinical presentation of several GI disorders. It also describes diagnostic criteria, differential diagnosis, and management methods for GI disorders.

• Part 20, “Evaluation and Management of Infectious Disease”

• Chapter 232, “Infectious Diarrhea” (pp. 1243-1251)

This chapter describes characteristics of three types of infectious diarrhea and identifies the pathophysiology, clinical presentation, treatment options, and possible causes of the disorder.

Week 6: Evaluation and Management of Gastrointestinal Disorders

Patients with gastrointestinal (GI) disorders face many daily challenges as they adhere to treatment and management plans. Consider Debbi Wynn, a patient with Crohn’s disease. Wynn compares her disorder to colon cancer, as a variety of medications can treat symptoms but with considerable risks and complications. Her medication regimen and diet restrictions prevent her from accepting invitations to dinner, drinks, movies, and shopping. Sometimes, unexpected “flare-ups” cause her to miss out on important family events such as weddings and funerals. Wynn often faces the challenges alone, as she feels unable to tell others about the adverse effects including intense pain, nausea, bowel obstructions, dehydration, fatigue, and depression (Wynn, 2012). As the advanced practice nurse, you must not only evaluate and treat patients like Wynn, but also help them to develop management plans that will minimize daily challenges related to their disorders.

This week, you examine potential diagnoses for patients with GI disorders. You also evaluate the role of patient information in diagnosis and treatment.

Learning Objectives

By the end of this week, students will:

• Assess differential diagnoses for patients with gastrointestinal disorders


• Analyze the role of patient information in differential diagnosis


• Evaluate patient treatment options for gastrointestinal disorders


• Understand and apply key terms, concepts, and principles related to the evaluation and management of gastrointestinal disorders


• Analyze pattern recognition in patient diagnoses