PRAC 6531 Week 6 Episodic Visit: Gastrointestinal Focused Note
Gastrointestinal Focused Note
Patient Information:
Initials: T.N. Age: 42 years old Sex: Male Race: Caucasian
S.
CC: “I have experienced abdominal discomfort and diarrhea for three days.”
HPI: T.N. is a 42-year-old Caucasian male presenting with abdominal cramping and watery diarrhea that commenced three days prior. He characterizes the pain as diffuse, with a mild to moderate intensity rated at 5 out of 10 on a pain scale, and cramp-like in quality. The commencement was abrupt, with no prior occurrences of comparable crises. The diarrhea is non-bloody, happening 5 to 6 times per day, accompanied by bloating and mild nausea, without vomiting. He refutes the presence of fever, chills, or weight loss. He indicates that he consumed takeout fish two nights ago, which may have precipitated the symptoms. He has administered loperamide with negligible alleviation. No recent travel or identified ill contacts. He refutes the presence of constipation, hematochezia, or melena.
Current Medications:
- Lisinopril 10 mg orally once daily for hypertension
- Atorvastatin 20 mg orally at bedtime for hyperlipidemia
- Loperamide 2 mg as needed for diarrhea (administered twice in the last 24 hours)
Allergies: Penicillin (rash)
PMHx:
- Hypertension (diagnosed 3 years ago)
- Hyperlipidemia
- No history of GI disease
PSHx:
- Appendectomy at age 16
- Right inguinal hernia repair at age 35
- No surgical complications
Soc Hx: T.N. serves as a warehouse supervisor and resides with his spouse and two adolescent children. He abstains from smoking and consumes alcohol socially, typically 1 to 2 beers on weekends. He refutes allegations of illegal drug consumption. He engages in moderate physical exercise (walking three times a week) and consistently utilizes a seatbelt. He possesses functional smoke detectors in his residence and a nurturing familial atmosphere. He refutes the allegation of texting while operating a vehicle. He has lately resumed work following his vacation and reported heightened work-related stress.
Fam Hx: Father has type 2 diabetes and coronary heart disease. Mother suffers from hypothyroidism and gastroesophageal reflux disease (GERD). One sibling has Crohn’s disease. There is no familial history of colorectal cancer. Children exhibit good health.
ROS:
GENERAL: Denies experiencing fever, chills, exhaustion, or unintended weight loss.
HEENT: Denies headache, visual disturbances, auditory impairment, nasal obstruction, or pharyngitis.
SKIN: Denies current rash, lesions, or pruritus; reports a history of rash associated with previous penicillin usage.
CARDIOVASCULAR: Denies experiencing chest discomfort, palpitations, or edema in the lower extremities.
RESPIRATORY: Denies cough, shortness of breath, wheezing, or sputum expectoration.
GASTROINTESTINAL: Patient reports three days of generalized abdominal cramps and non-bloody watery diarrhea; denies nausea, vomiting, hematochezia, melena, or constipation.
GENITOURINARY: Denies dysuria, hematuria, urine frequency, or alterations in urinary habits.
NEUROLOGICAL: Denies experiencing dizziness, headache, numbness, tingling, or weakness.
MUSCULOSKELETAL: Denies the presence of joint pain, muscular discomfort, or rigidity.
HEMATOLOGIC: Denies susceptibility to simple bruising or hemorrhaging.
LYMPHATICS: No reported lymphadenopathy or discomfort.
PSYCHIATRIC: Denies experiencing anxiety, depression, or sleep disturbances.
ENDOCRINOLOGICAL: Denies intolerance to heat or cold, polyuria, or polydipsia.
ALLERGIES: Allergic to penicillin, resulting in a rash. Denies the existence of dietary or environmental allergies.
O.
Vital Signs: BP 128/78 mmHg, HR 84 bpm, Temp 98.6°F, RR 16, SpO₂ 98% RA; Wt. 198 lbs., BMI 28.5.
GENERAL: Patient appears alert, oriented, and in no acute distress. Ambulates independently. Maintains eye contact. Answers questions appropriately. Mild abdominal discomfort noted with movement.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Nasal mucosa is moist, with no congestion. Oropharynx clear, no tonsillar enlargement or exudate. Tympanic membranes are intact bilaterally.
SKIN: Warm, dry, and intact. No visible rashes.
CARDIOVASCULAR: Regular rate and rhythm; no murmurs, rubs, or gallops.
RESPIRATORY: Clear to auscultation bilaterally. No wheezing, rales, or rhonchi.
GASTROINTESTINAL: Abdomen soft, non-distended, hyperactive bowel sounds. Mild diffuse tenderness noted, no rebound or guarding. No hepatosplenomegaly or palpable masses.
Diagnostic results: Negative stool occult blood test; CBC shows mild leukocytosis. Electrolytes normal. No imaging ordered at this time.
A.
Differential Diagnoses:
- Acute Infectious Gastroenteritis (A09): Primary diagnosis attributed to the patient’s recent seafood consumption, characterized by the abrupt onset of watery diarrhea, abdominal discomfort, and the absence of blood in the stool or systemic manifestations. The CDC guidelines endorse this diagnosis because of the clinical presentation, lack of red flags, and a self-limiting trajectory in otherwise healthy adults (Meier, 2021).
- Clostridioides difficile Infection (A04.7): Considered due to recent loperamide usage and ongoing diarrhea; despite no known antibiotic use, community-acquired cases are present. The CDC advises stool toxin testing if symptoms endure beyond three days or deteriorate, particularly in individuals exhibiting moderate leukocytosis and diarrhea that does not respond to conservative treatment (Donskey, 2023).
- Irritable Bowel Syndrome, Diarrhea-Predominant (K58.0): Persistent functional gastrointestinal condition marked by recurring abdominal pain and abnormal bowel patterns. Despite T.N.’s acute symptoms, if they recur or continue beyond one week without evidence of infection or inflammation, irritable bowel syndrome with diarrhea (IBS-D) should be contemplated. The Rome IV criteria and ACG guidelines advocate for follow-up and assessment if symptoms persist chronically (Carmona-Sánchez et al., 2021).
- Request stool analyses if diarrhea continues for more than 5 days or deteriorates (such as stool culture, ova and parasites, C. difficile toxin) (Fleckenstein et al., 2021).
- Promote oral hydration with electrolyte-enriched fluids (such as Pedialyte, Gatorade) (Hasan et al., 2021).
- Administer loperamide 2 mg orally as needed, not exceeding 8 mg per day; discontinue if bloody stools or fever occur (Schmidt et al., 2022).
- Advise adherence to the BRAT diet for 48 hours; abstain from dairy, coffee, and fatty foods (Meier, 2021).
- Educate on appropriate food handling practices, particularly about seafood.
- No urgent referrals are warranted; reevaluate if there is no progress.
- Follow up in 72 hours or earlier if symptoms deteriorate.
- Outline return precautions for dehydration or indications of systemic sickness.
Reflection: This example underscored the significance of a comprehensive food and exposure history in the assessment of acute gastrointestinal symptoms. Considering the patient’s recent consumption of seafood and the lack of concerning symptoms, I concur with my preceptor’s conservative approach, emphasizing water and symptomatic alleviation (Fleckenstein et al., 2021). Nevertheless, I would have more emphatically strengthened nutritional instruction to avert such incidents. T.N.’s age and history of hypertension underscore the necessity for vigilant monitoring of electrolyte levels and hydration status. As a middle-aged Caucasian male without discernible socioeconomic obstacles, access to follow-up treatment and education was uncomplicated (Schmidt et al., 2022). This example underscored the need for patient-centered care, highlighting the duration of symptoms and the monitoring of red flags. In subsequent assessments, I would investigate dietary practices more thoroughly and provide instruction on food safety and infection control.
References
Carmona-Sánchez, R., Carrera-Álvarez, M., & Peña-Zepeda, C. (2021). Prevalence of primary eosinophilic colitis in patients with chronic diarrhea and diarrhea-predominant irritable bowel syndrome. Revista De Gastroenterología De México (English Edition), 87(2), 135–141. https://doi.org/10.1016/j.rgmxen.2021.07.002
Donskey, C. J. (2023). Update on Clostridioides difficile Infection in Older Adults. Infectious Disease Clinics of North America, 37(1), 87–102. https://doi.org/10.1016/j.idc.2022.10.001
Fleckenstein, J. M., Kuhlmann, F. M., & Sheikh, A. (2021). Acute bacterial gastroenteritis. Gastroenterology Clinics of North America, 50(2), 283–304. https://doi.org/10.1016/j.gtc.2021.02.002
Hasan, H., Nasirudeen, N. A., Ruzlan, M. a. F., Jamil, M. a. M., Ismail, N. a. S., Wahab, A. A., & Ali, A. (2021). Acute infectious gastroenteritis: the causative agents, OMicS-Based detection of antigens and novel biomarkers. Children, 8(12), 1112. https://doi.org/10.3390/children8121112
Meier, J. L. (2021). Viral acute gastroenteritis in special populations. Gastroenterology Clinics of North America, 50(2), 305–322. https://doi.org/10.1016/j.gtc.2021.02.003
Schmidt, M. A., Groom, H. C., Rawlings, A. M., Mattison, C. P., Salas, S. B., Burke, R. M., Hallowell, B. D., Calderwood, L. E., Donald, J., Balachandran, N., & Hall, A. J. (2022). Incidence, etiology, and healthcare utilization for acute gastroenteritis in the community, United States. Emerging Infectious Diseases, 28(11), 2234–2242. https://doi.org/10.3201/eid2811.220247
CLICK HERE TO ORDER A PLAGIARISM-FREE PAPER
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
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.
Rubric
PRAC_6531_Week6_Assignment2_Rubric
| Criteria | Ratings | Pts |
|---|---|---|
| This criterion is linked to a Learning OutcomeOrganization of Write-up | 10 to >6.0 ptsExcellentAll information organized in logical sequence; follows acceptable format and utilizes expected headings.
6 to >3.0 ptsGoodInformation generally organized in logical sequence; follows acceptable format and utilizes expected headings. 3 to >0.0 ptsFairErrors in format; information intermittently organized. Headings are used some of the time. 0 ptsPoorErrors in format; information disorganized. Headings are not used appropriately. |
10 pts |
| This criterion is linked to a Learning OutcomeThoroughness of History | 20 to >15.0 ptsExcellentThoroughly documents all pertinent history components for type of note; includes critical as well as supportive information.
15 to >11.0 ptsGoodDocuments most pertinent examination components. 11 to >7.0 ptsFairDocuments some pertinent examination components. 7 to >0 ptsPoorPhysical examination cursory; misses several pertinent components. |
20 pts |
| This criterion is linked to a Learning OutcomeHistory of Present Illness | 10 to >6.0 ptsExcellentThoroughly documents all 8 aspects of HPI and pertinent other data relevant to chief complaint. Includes critical as well as supportive information.
6 to >4.0 ptsGoodDocuments at least 6 aspects of the HPI and pertinent other data relevant to chief complaint. Includes critical information. 4 to >2.0 ptsFairDocuments at least 4 aspects of HPI and some data pertinent to chief complaint. Lacks some critical information or rambling in history. 2 to >0 ptsPoorMissing many aspects of HPI and pertinent data. Critical information missing. |
10 pts |
| This criterion is linked to a Learning OutcomeThoroughness of Physical Exam | 10 to >7.0 ptsExcellentThoroughly documents all pertinent examination components for type of note.
7 to >4.0 ptsGoodDocuments most pertinent examination components. 4 to >2.0 ptsFairDocuments some pertinent examination components. 2 to >0 ptsPoorPhysical examination cursory; misses several pertinent components. |
10 pts |
| This criterion is linked to a Learning OutcomeDiagnostic Reasoning | 10 to >7.0 ptsExcellentAssessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests.
7 to >4.0 ptsGoodAssessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems. 4 to >2.0 ptsFairAssessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests. 2 to >0 ptsPoorAssessment 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 | 20 to >15.0 ptsExcellentTreatment plan addresses all issues raised by diagnoses, excellent insight into patient’s needs. Medications prescribed are appropriate and full prescription is included. Evidence based decisions. Cost effective treatment.
15 to >10.0 ptsGoodTreatment plan addresses most issues raised by diagnoses. Medications prescribed are appropriate but include 1 or 2 error in writing prescription. 10 to >5.0 ptsFairTreatment plan fails to address most issues raised by diagnoses. Medications are inappropriate or include 3 or more errors in writing prescription. 5 to >0 ptsPoorMinimal treatment plan addressed. Medications are inappropriate or poorly written prescription. |
20 pts |
| This criterion is linked to a Learning OutcomePatient Education / Follow Up / Reflection | 10 to >8.0 ptsExcellentPatient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Follow up plan in appropriate and reflects acuity of illness. Reflection is thoughtful and in depth.
8 to >5.0 ptsGoodPatient education addresses most issues raised by diagnoses. Follow up plan is appropriate but lacks specifics Reflection is thoughtful and in depth. 5 to >3.0 ptsFairPatient education fails to address most issues raised by diagnoses. Follow up plan is lacking specifics or is inappropriate for patient acuity. Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently. 3 to >0 ptsPoorMinimal patient education addressed. Follow up plan is inappropriate Reflection is absent. |
10 pts |
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting English writing standards: Correct grammar, mechanics, and proper punctuation. Professional language utilized | 5 ptsExcellentUses correct grammar, spelling, and punctuation with no errors. Professional language utilized.
4 ptsGoodContains a few (1-2) grammar, spelling, and punctuation errors. Contains a few errors (1 or 2) in professional language use. 2 ptsFairContains several (3-4) grammar, spelling, and punctuation errors. Contains several errors (3 -4) in professional language use. 0 ptsPoorContains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. Contains many errors in professional language use. |
5 pts |
| This criterion is linked to a Learning OutcomeScholarly References and Clinical Practice Guidelines. The assignment includes a minimum of 3 scholarly references that are not older than 5 years. Clinical practice guidelines are included if applicable. | 5 ptsExcellentContains parenthetical/in-text citations and at least 3 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable.
4 ptsGoodContains parenthetical/in-text citations and at least 2 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable. 2 ptsFairContains parenthetical/in-text citations and at least 1 evidenced based reference less than 5 years old is listed. Clinical practice guidelines are not cited if applicable. 0 ptsPoorContains no parenthetical/in-text citations and 0 evidenced based references listed. Clinical practice guidelines are not cited if applicable. |
5 pts |
Total Points: 100
How to pass nursing school exams
Help with nursing care plans
Nursing homework help online
Best study guides for nursing students
Academic writing help for nursing students
Clinical reasoning practice for nurses
NCLEX-RN preparation resources
APA formatting help for nursing assignments
Online tutoring for nursing students
Evidence-based practice in nursing education
