Case study: HPI: L.B. a 61-year-old African American male, presents to the clinic today with the report of diarrhea and vomiting intermittently for the last three months. The patient reports a dull aching pain in his lower stomach and rates his pain a five out of ten on the pain scale. He reports that he is “unable to hold anything down.” He states that when he eats, it makes him vomit. The patient reports taking amoxicillin, which seemed to help with the vomiting but never stopped the diarrhea. He also reports weight loss of about 20 pounds over the past three months, that was unintentional. He reports a history of a kidney transplant
Case study: HPI: L.B. a 61-year-old African American male, presents to the clinic today with the report of diarrhea and vomiting intermittently for the last three months. The patient reports a dull aching pain in his lower stomach and rates his pain a five out of ten on the pain scale. He reports that he is “unable to hold anything down.” He states that when he eats, it makes him vomit. The patient reports taking amoxicillin, which seemed to help with the vomiting but never stopped the diarrhea. He also reports weight loss of about 20 pounds over the past three months, that was unintentional. He reports a history of a kidney transplant
Episodic/Focus Note Template
Patient Information: L.B. 61 year old male African American
Initials, Age, Sex, Race
S.
CC: Diarrhea
HPI: L.B. a 61-year-old African American male, presents to the clinic today with the report of diarrhea and vomiting intermittently for the last three months. The patient reports a dull aching pain in his lower stomach and rates his pain a five out of ten on the pain scale. He reports that he is “unable to hold anything down.” He states that when he eats, it makes him vomit. The patient reports taking amoxicillin, which seemed to help with the vomiting but never stopped the diarrhea. He also reports weight loss of about 20 pounds over the past three months, that was unintentional. He reports a history of a kidney transplant. This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You must start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:
Location: head
ORDER A CUSTOMIZED, PLAGIARISM-FREE Case study: HPI: L.B. a 61-year-old African American male, presents to the clinic today with the report of diarrhea and vomiting intermittently for the last three months. The patient reports a dull aching pain in his lower stomach and rates his pain a five out of ten on the pain scale. He reports that he is “unable to hold anything down.” He states that when he eats, it makes him vomit. The patient reports taking amoxicillin, which seemed to help with the vomiting but never stopped the diarrhea. He also reports weight loss of about 20 pounds over the past three months, that was unintentional. He reports a history of a kidney transplant HERE
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Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications:
Aspirin 81 mg tablet once daily
Atorvastatin 10 mg tablet once daily
Centrum 1 tablet once daily
Glucagon Emergency Kit for hypoglycemic emergency
Hydralazine 25 mg 1 tablet twice daily for hypertension
Isosorbide Dinitrate 20 mg 1 tablet twice daily for hypertension
Lantus 25 units at bedtime for diabetes
Metoprolol Succinate ER 50 mg 1 tablet once daily for heart rate
Mycophenolate Mofetil 250 mg 3 tablets every 12 hours
Pepcid 20 mg tablet 1 tablet once daily for acid reflux
Prednisone 5 mg tablet once daily for organ transplant
Tacrolimus 1 mg 2 tablets twice daily for organ transplant
Zofran 4 mg 1 tablet 3 times a day as needed for vomiting
include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies:
Denies environmental allergies
Denies food allergies
Denies latex allergies
Denies allergies to foods include medication, food, and environmental allergies separately (a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs intolerance).
PMHx:
Anemia
CKD
Type 2 Diabetes
Hypertension
Hyperlipidemia
Diverticula of the intestine
Tdap- 8/16/2018
Flu- 9/27/2021
Prevnar- 1/18/2023
Covid #1-11/01/21 Covid #2-4/16/2021
Colonoscopy-2/10/2023
Kidney Transplant- 3/18/2006
Cardiac Defibrillator- 3/01/2019
immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (i.e., previous and current use), any other pertinent data. Always add some health promo question here (e.g., whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system).
Fam Hx:
Father, who died at age 88, had a history of carcinoma of the prostate.
Mother died at age 79, had a history of hypertension, diabetes, and hyperlipidemia.
Maternal grandmother
Maternal grandfather
Paternal grandfather
Paternal grandmother
illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: reports weight loss of 20 pounds, fatigue
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: Reports nausea, vomiting, and diarrhea. Reports dull “achy” pain to lower abdomen. No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e., General: Head: EENT: etc.).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
A.
Differential Diagnoses (list a minimum of three differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?
Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).
References
You are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.