Analyze the subjective portion of the note. List additional information that should be included in the documentation.

The Episodic Note case study shows that the patient, a 45-year old female with constipation and abdominal pains, presents as an Episodic note. According to the patient, the abdominal pain began suddenly in the lower quadrant of her abdomen. It is described as being aching and cramping and has been there for 24 hours. She also reported that she had not experienced bowel movements in three days, and her stool is hardened and smaller. She has had irritable bowel syndrome before and was previously diagnosed with diverticulosis.

Additional information that should be included in the documentation from the subjective portion of the note include the intensity and duration of the pain, any associated symptoms such as nausea or vomiting, and the patient’s past medical and surgical history.

The documentation should include additional information from the objective section of the note, such as the results of the physical exam, which includes vital signs and abdominal examinations, and any relevant positive or negative findings.

Both objective and subjective information are used to support the assessment. The patient’s report of abdominal pain and constipation align with the physical examination findings of abdominal tenderness and decreased bowel sounds.

A complete blood count and blood chemistry panel are appropriate diagnostic tests for this situation. Abdominal imaging studies, such as CT scans or ultrasound, would also be recommended. The results of these tests would be used to evaluate the patient’s overall health status and to help determine the cause of the abdominal pain and constipation.

Based on all the information provided, I accept the current diagnosis as diverticulitis. I will consider possible other conditions as part of the differential diagnosis. These include IBS, IBS-related inflammatory bowel disease and gastrointestinal infections. Additional testing and further evaluation may be necessary to confirm the diagnosis and rule out other potential causes of the patient’s symptoms.

References:

National Institute of Diabetes and Digestive and Kidney Diseases. (n.d.). Irritable bowel syndrome. Retrieved at https://www.niddk.nih.gov/health-information/digestive-diseases/irritable-bowel-syndrome

National Institute of Diabetes and Digestive and Kidney Diseases. (n.d.). Diverticulosis

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