Learning Goal: I’m working on a nursing multi-part question and need an explanation and answer to help me learn.The patient I saw was a 68-year-old Hispanic female present with the chief complaint of vomiting and diarrheaV/S Bp127/64, P68, T97.8, O2 97%, R16 BMI 40 Was diagnosed with acute virus gastritis Was treated with IV fluid Was negative for COVID, Flu, and C-diff Medical history: DM 2, Morbid Obesity, Hyperlipidemia, HTN Assignment 2: Episodic Visit: Gastrointestinal Focused NotePhoto Credit: PexelsFor 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 SAFE ASSIGN.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.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 7Submit 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 and Grading InformationTo submit your completed Assignment for review and grading, do the following:
Requirements: SOAP note | .doc file
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