What was your plan for diagnostics and primary diagnosis

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Reference no: EM134018093

Assignment:

Please make a SOAP note

The patient is a 45-year-old male who presents with a chief complaint of persistent abdominal pain and bloating for the past three weeks. The pain is localized to the lower right quadrant and worsens after eating. The patient reports a medical history of hypertension, for which he takes amlodipine 5mg daily. He denies any significant past surgeries or allergies. There is no family history of gastrointestinal disorders. The patient also mentions feeling stressed lately due to work-related issues

With this patient in mind, consider the following:

Subjective: What details did the patient provide regarding the personal and medical history?

Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings.

Describe whether the patient presented with any morbidities and psychosocial issues.

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. 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? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

Reflection notes: What was your "aha" moment? What would you do differently in a similar patient evaluation

Reference no: EM134018093

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