Focused Assessment of Adult Assignment
Focused Assessment of Adult Assignment
Case Presentation
Susan, a fifty-five year old asian store manager, had recently been waking up in the middle of the night with abdominal pain. This was happening several nights a week. She was also experiencing occasional discomfort in the middle of the afternoon. Susan decided to schedule an appointment with her physician.
The doctor listened as Susan described her symptoms and then asked her some questions. He noted that Susan’s appetite had suffered as a result of the pain he was experiencing and as a result of the fear that what she was eating may be responsible for the pain.
The doctor referred Susan to a physician that specialized in internal medicine and had Susan make an appointment for a procedure called an endoscopy. The endoscopy was performed at a hospital later that week. During the procedure, a long, thin tube was inserted into Susan’s mouth and directed into his digestive tract. The end of the tube was equipped with a light source and a small camera which allowed the doctor to observe the interior of Susan’s stomach. The endoscope was also equipped with a small claw-like structure that the doctor could use in order to obtain a small tissue sample from the lining of Susan’s stomach, if required.
The endoscopy revealed that Susan had a peptic ulcer. Analysis of a tissue sample taken from the site showed that Susan also had an infection that was caused by Helicobacter pylori bacteria. The doctor who performed the endoscopy gave Susan prescriptions for two different antibiotics and a medication that would decrease the secretion of stomach acid. The doctor also instructed Susan to schedule an appointment in 6 months.
Assignment 4 (Individual assignment)
Adult with GI complaint
- State the concerning symptom, that is chief complaint
(1 point)
- Conduct a history of present illness (HPI) or analysis of symptom
(4 points) 7 factors
- Conduct and document a focused physical examination
[include the heart and lungs]
(6 points)
- What is your diagnosis? (Base the diagnosis on your history and physical). (1 points)
- When would you have this patient follow up and why?
(1 point)
- List dietary food that you be accepted by her culture for this diagnosis with rational ( 7 points)
Total of 20 pts
