Posted: May 1st, 2023

Health Assign WK 10 Using evidence-based resources

Health Assign WK 10 Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
____________________

The subjective portion of a medical note typically includes information gathered from the patient, such as their symptoms, medical history, and medications. In addition to this, the following information should also be included in the documentation:

Duration and progression of symptoms
Severity of symptoms
Factors that exacerbate or alleviate symptoms
Any relevant social or family history
Any recent changes in medication or lifestyle that may be relevant
The objective portion of a medical note typically includes information gathered from a physical examination, laboratory tests, and other diagnostic procedures. In addition to this, the following information should also be included in the documentation:

Vital signs
Results of physical examination, including any abnormalities
Results of any laboratory tests or imaging studies performed
Any relevant medical history, such as allergies or previous surgeries
The assessment should be supported by both the subjective and objective information. For example, if a patient reports symptoms of a respiratory infection, the physical examination should reveal signs of inflammation or infection in the respiratory system.

Diagnostics may be appropriate for this case if the underlying cause of the patient’s symptoms is unclear. Results from diagnostic tests, such as blood tests or imaging studies, can help identify any abnormalities or underlying conditions that may be causing the patient’s symptoms.

Whether to accept or reject the current diagnosis would depend on the quality and relevance of the available evidence. Three possible differential diagnoses for this patient could be:

Gastroesophageal reflux disease (GERD)
Peptic ulcer disease
Gastritis
GERD, peptic ulcer disease, and gastritis are all common causes of abdominal pain and can present with similar symptoms. To differentiate between these conditions, a thorough medical history, physical examination, and diagnostic tests may be necessary.

References:

Vakil N. Peptic ulcer disease. Primary care. 2015;42(2):223-237.
Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. American Journal of Gastroenterology. 2013;108(3):308-328.
Almadi MA, Barkun AN, Kuipers EJ, et al. Management of acid peptic disorders. Journal of gastroenterology and hepatology. 2012;27(1):7-14.

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