PRAC 6531 EPISODIC VISIT: GASTROINTESTINAL FOCUSED NOTE ESSAY

PRAC 6531 EPISODIC VISIT: GASTROINTESTINAL FOCUSED NOTE ESSAY

PRAC 6531 EPISODIC VISIT: GASTROINTESTINAL FOCUSED NOTE ESSAY

GASTROINTESTINAL FOCUSED NOTE

Patient Information:

Initials: S.L                Age: 72 years           

Sex: Female              Race: Asian

S.

CC (chief complaint) “Epigastric pain.”

HPI: S.L is a 72-year-old Asian female who presented with a chief complaint of epigastric pain. The epigastric pain began two weeks ago and has worsened over time. She described the pain as burning but non-radiating. She also reported losing appetite, nausea, vomiting, belching, and bloating. However, she denied having regurgitation, heartburn, abdominal pain/discomfort, nausea, or vomiting. She rated the epigastric pain as 4/10. The patient used Motrin to alleviate an ankle injury she sustained a month ago.

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Current Medications: Motrin 400 mg PRN.

Allergies: No food/drug allergies.

PMHx: No history of chronic illnesses. No past surgeries. Immunization is current.

Soc Hx: S.L is a retired hotel supervisor with a Diploma in Hotel Management. She is married and has three children daughter, 48, 43, and 38 years. She admits to taking 2 glasses of red wine occasionally and smoking 2 PPD but denies illicit drug use. She also take 3-4 cups of caffeine per day. Her hobbies are traveling and watching TV.

Fam Hx: The paternal grandfather died at 89 years from Liver failure. The father had HTN and heart failure. Her siblings and children are alive and well.

ROS

GENERAL: Negative for weight gain/loss, fatigue, body weakness, fever, or chills.

HEENT: Eyes: Negative for visual changes, eye pain, or excessive tearing. Ears, Nose, Throat: Reports sore throat and swallowing difficulty. Denies hearing loss, tinnitus, or ear discharge. Denies sinus pain, rhinorrhea, nasal discharge, or epistaxis. Denies sore tongue, bleeding gums, or tooth pain.

SKIN: Denies rash, bruises, or itching.

CARDIOVASCULAR: Negative for palpitations, chest pain, dyspnea at rest, or edema.

RESPIRATORY: Negative for chest pain, cough, dyspnea, wheezing, or sputum.

GASTROINTESTINAL: Reports nausea, vomiting, heartburn, anorexia, belching, bloating, and epigastric pain. Denies regurgitation, constipation, diarrhea, or rectal bleeding.

GENITOURINARY: Denies burning on urination or increased PV discharge.

NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, or tingling in the extremities.

MUSCULOSKELETAL: Denies muscle/back pain, joint pain, or stiffness.

HEMATOLOGIC: Denies anemia, bleeding, or bruising.

LYMPHATICS: Denies enlarged nodes.

PSYCHIATRIC: Denies a history of depression or anxiety.

ENDOCRINOLOGIC: Denies excessive sweating, cold/heat intolerance, polyuria, or polydipsia.

ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis.

O.

Physical exam

Vital Signs: HR-84; BP- 120/80; RR- 20; Temp-98.42; Sp02-100%. Height- 5’4      Weight-185 lbs. BMI- 31.8   

General. A 72-year-old Asian female patient. She is calm, alert, and in no acute distress. She is neat and appropriately dressed for the weather and function. She maintains eye contact, and her speech is clear and goal-directed.

Cardiovascular: No neck vein distension or edema. Regular heart rate and rhythm. S1 and S2 are present. No systole or friction rubs.

Respiratory: Even chest rise and fall. Smooth and unlabored respirations. Lungs are clear bilaterally.

Gastrointestinal: Normoactive bowel sounds, mild epigastric tenderness, and no abdominal tenderness, masses, or organomegaly.

Diagnostic results: H pylori stool antigen test-negative

Complete blood cell (CBC) count- WNL.

A.

Differential Diagnoses

Acute Gastritis:  Clinical manifestations include epigastric pain/discomfort, loss of appetite, nausea, vomiting, belching, and bloating (Rugge et al., 2020). The patient presents with non-radiating epigastric pain, anorexia, nausea, vomiting, belching, and bloating, making acute gastritis the primary diagnosis.

Peptic Ulcer Disease (PUD): PUD manifests with severe epigastric pain 2–5 hours after meals or in the evening, nausea, vomiting, early satiety, heart burn, chest discomfort, and epigastric tenderness (Narayanan et al., 2018; Kamada et al., 2021). The patient has epigastric pain, nausea, and vomiting making PUD  a differential diagnosis.

Gastroesophageal reflux disease (GERD): The cardinal symptoms of GERD are heartburn, regurgitation, and dysphagia (Maret-Ouda et al., 2020). Other clinical features include epigastric pain, belching, and nausea. The abnormal reflux can cause chest pain, wheezing, coughing, dental erosions, and hoarseness (Clarrett & Hachem, 2018). GERD is a differential diagnosis based on positive symptoms like epigastric pain, nausea, and belching.

P.

 Acute Gastritis

Diagnostic studies: A double-contrast examination to best reveal gastric erosions (Shah et al., 2021).

Referrals: Refer to a gastroenterologist if the condition becomes complicated.

Therapeutic Interventions: Omeprazole 40 mg orally once daily for 4-8 weeks.

Patient Education: Health education focused on the risk factors for gastritis, like NSAID use, alcohol consumption, excessive caffeine intake, smoking, and corticosteroid use. The patient was educated that long-term NSAID use has a high risk for acute gastritis (Shah et al., 2021).

Follow-up: Follow-up after two weeks to assess treatment response.

Reflection

I agree with the preceptor’s primary diagnosis (Acute Gastritis) and treatment interventions for this patient. The patient presented with the cardinal symptoms of Acute Gastritis. In a different situation, I would assess the patient’s lifestyle to identify factors contributing to the symptoms. Health promotion should focus on the risk factors for gastritis. Patients should be advised to reduce alcohol and caffeine consumption like coffee and tea to avoid triggering gastritis symptoms (Shah et al., 2021). In addition, patients with gastritis should be advised to eat a well-balanced diet and quit smoking.

References

Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal Reflux Disease (GERD). Missouri Medicine, 115(3), 214–218.

Kamada, T., Satoh, K., Itoh, T., Ito, M., Iwamoto, J., Okimoto, T., Kanno, T., Sugimoto, M., Chiba, T., Nomura, S., Mieda, M., Hiraishi, H., Yoshino, J., Takagi, A., Watanabe, S., & Koike, K. (2021). Evidence-based clinical practice guidelines for peptic ulcer disease 2020. Journal of gastroenterology, 56(4), 303–322. https://doi.org/10.1007/s00535-021-01769-0

Maret-Ouda, J., Markar, S. R., & Lagergren, J. (2020). Gastroesophageal reflux disease: a review. Jama, 324(24), 2536-2547. https://doi.org/10.1001/jama.2020.21360

Narayanan, M., Reddy, K. M., & Marsicano, E. (2018). Peptic Ulcer Disease and Helicobacter pylori infection. Missouri medicine, 115(3), 219–224.

Rugge, M., Sugano, K., Sacchi, D., Sbaraglia, M., & Malfertheiner, P. (2020). Gastritis: An Update in 2020. Current Treatment Options in Gastroenterology, 1-16. https://doi.org/10.1007/s11938-020-00298-8

Shah, S. C., Piazuelo, M. B., Kuipers, E. J., & Li, D. (2021). AGA Clinical Practice Update on the Diagnosis and Management of Atrophic Gastritis: Expert Review. Gastroenterology, 161(4), 1325–1332.e7. https://doi.org/10.1053/j.gastro.2021.06.078

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EPISODIC VISIT: GASTROINTESTINAL FOCUSED NOTE

For this Assignment, you will work with a patient with a gastrointestinal condition that you examined during the last three weeks. You will complete your second Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, PMH, socioeconomic, cultural background, etc. In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes.

Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.

Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

LEARNING RESOURCES

Required Readings

Fowler, G. C. (2020). Pfenninger and Fowler’s procedures for primary care (4th ed.). Elsevier.

Chapter 82, “Clinical Anorectal Anatomy and Digital Examination” (pp. 570–572)

Chapter 83. “Anoscopy” (pp. 573–576)

Chapter 87, “Office Treatment of Hemorrhoids” (pp. 596–606) specifically pp. 604 -606 external hemorrhoidal tags

Chapter 94, “Esophageal Foreign Body Removal” (pp. 676–679)

Chapter 95, “Inguinal Hernia Reduction” (pp. 680–683)

Chapter 20,: “Management of Fecal Impaction” (pp. 1382–1383)

Practicum Resources

HSoft Corporation. (2019). Meditrek: HomeLinks to an external site.. https://edu.meditrek.com/Default.html

Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.

Walden University Field Experience. (2019a). Field experience: College of Nursing.Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/home

Walden University Field Experience. (2019b). Student practicum resources: NP student orientation.Links to an external site. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation

Walden University. (2019). MSN nurse practitioner practicum manual.Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments

Document: Episodic/Focus Note Template (Word document)Download Episodic/Focus Note Template (Word document)

To prepare:

Use the Episodic/Focused Note Template found in the Learning Resources for this week to complete this Assignment.

Select a patient that you examined during the last three weeks based on any gastrointestinal conditions. With this patient in mind, address the following in a Focused Note:

Assignment:

Subjective: What details did the patient provide regarding her personal and medical history?

Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

Reflection notes: What would you do differently in a similar patient evaluation?

Note: Your Focused Note Assignment must be signed by Day 7 of Week 6.

BY DAY 7

Submit your Episodic/Focused Note Assignment. (Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 6.)

SUBMISSION INFORMATION

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

To submit your completed assignment, save your Assignment as WK6Assgn2_LastName_Firstinitial

Then, click on Start Assignment near the top of the page.

Next, click on Upload File and select Submit Assignment for review.

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Rubric

PRAC_6531_Week6_Assignment2_Rubric

PRAC_6531_Week6_Assignment2_Rubric

Criteria Ratings Pts

This criterion is linked to a Learning OutcomeOrganization of Write-up

30 to >26.0 pts

Excellent

All information organized in logical sequence; follows acceptable format

26 to >23.0 pts

Good

Information generally organized in logical sequence; follows acceptable format23 to >20.0 pts

Fair

Errors in format; information intermittently organized

20 to >0 pts

Poor

Errors in format; information disorganized

30 pts

This criterion is linked to a Learning OutcomeThoroughness of History

20 to >17.0 pts

Excellent

Thoroughly documents all pertinent history components for type of note; includes critical as well as supportive information

17 to >15.0 pts

Good

Documents most pertinent history components; includes critical information

15 to >13.0 pts

Fair

Fails to document most pertinent history components; Lacks some critical information or rambling in history

13 to >0 pts

Poor

Minimal history; critical information missing

20 pts

This criterion is linked to a Learning OutcomeThoroughness of Physical Exam

10 to >8.0 pts

Excellent

Thoroughly documents all pertinent examination components for type of note

8 to >7.0 pts

Good

Documents most pertinent examination components

7 to >6.0 pts

Fair

Documents some pertinent examination components

6 to >0 pts

Poor

Physical examination cursory; misses several pertinent components

10 pts

This criterion is linked to a Learning OutcomeDiagnostic Reasoning

10 to >8.0 pts

Excellent

Assessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests

8 to >7.0 pts

Good

Assessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems.

7 to >6.0 pts

Fair

Assessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests

6 to >0 pts

Poor

Assessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests

10 pts

This criterion is linked to a Learning OutcomeTreatment Plan/Patient Education

10 to >8.0 pts

Excellent

Treatment plan and patient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Evidence based decisions. Cost effective treatment. Reflection is thoughtful and in depth.

8 to >7.0 pts

Good

Treatment plan and patient education addresses most issues raised by diagnoses. Reflection is thoughtful and in depth.

7 to >6.0 pts

Fair

Treatment plan and patient education fail to address most issues raised by diagnoses. … Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently.

6 to >0 pts

Poor

Minimal treatment plan and/or patient education addressed … Reflection is absent.

10 pts

This criterion is linked to a Learning OutcomeWritten Expression and FormattingEnglish writing standards: Correct grammar, mechanics, and proper punctuation.

10 to >8.0 pts

Excellent

Uses correct grammar, spelling, and punctuation with no errors.

8 to >7.0 pts
Good

Contains a few (1-2) grammar, spelling, and punctuation errors.

7 to >6.0 pts

Fair

Contains several (3-4) grammar, spelling, and punctuation errors.

6 to >0 pts

Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

10 pts

This criterion is linked to a Learning OutcomeWritten Expression and FormattingThe assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed.
10 to >8.0 pts

Excellent

Contains parenthetical/in-text citations and at least 3 evidenced based references are listed.

8 to >7.0 pts

Good

Contains parenthetical/in-text citations and at least 2 evidenced based references are listed

7 to >6.0 pts

Fair

Contains parenthetical/in-text citations and at least 1 evidenced based reference is listed

6 to >0 pts
Poor

Contains no parenthetical/in-text citations and 0 evidenced based references listed.

10 pts

Total Points: 100

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