Rachel is a 20-year-old female who presents with complaints of decreased appetite fatigue, nausea and abdominal pain for the last 2-3 weeks. She describes the abdominal pain as sharp and is focused in the right epigastric area. Her typical diet consists of pizza, hot dogs, and salads. Rachel denies any association of her symptoms with food or hunger.ROS: Denies vomiting, diarrhea, or constipation.Past medical history: She delivered her son 6 months ago vaginally without complications. Her only other medical history includes a kidney infection 4 months ago. Social history: Smokes 7 cigarettes/day but admits, "I really don't need them. I am bored." Rachel lives with her boyfriend (father of her child) and his parents. She moved in, far away from her home, only recently. Her parents made her leave their house when she told them she was pregnant, and they have no contact with her. She state that she feels safe at home and is enjoying her baby. Her boyfriend helps with the baby, but often goes out at night with his friends and leaves her home with the baby. She feels a little isolated because everyone works during the day and she has no access to transportation. She is dependent on her in-laws if she needs to go anywhere by car, and they do not often support her need to go anywhere. Otherwise, she walks. She walked her today for her appointment. Medication: NKDA, takes birth control pills OBJECTIVE: Vital signs: Oral Temp 98.6, BP 120/80 left arm, sitting. Radial pulse of 68 and regular, RR: 12Eyes: PERRLA. EOMs are intact. Optic disks are sharp. Cardiac: Regular rate and rhythm, S1 S2, no murmurs, clicks or rubs. Respiratory: Breathing is steady, and unlabored. All lung fields are clear to auscultation. Abdomen: Soft with mild tenderness to palpation (TIP) in the RUQ with a positive Murphy's sign. No CVA tenderness. Genitourinary. A urine dipstick reveals positive protein. A urine HCG is negative.
Answer the following questions for the Case Study above
Reflect on the case study; discuss the following criteria as part of that reflection.
ANSWER THE FOLLOWING QUESTIONS
For each question please write the question first then the answer below it
- Introduction: Reflect on the case study; answer the following questions as part of that reflection. Introduce your paper including a brief description of your paper. Describe the purpose and plan for this paper.
- Subjective: What additional subjective information do you need from the patient?
- Objective: What additional physical exam findings are needed?
- Assessment: What additional history (past medical, surgical and family) exam findings are needed.
- Diagnosis(s) What is the most appropriate diagnosis(s) given the patient’s presentation. (include two differential diagnosis and ICD-10 codes)
- Assessment Findings: Include rationales based on your assessment findings to support your diagnosis(s).
- Plan: What labs and/or diagnostic testing, if any would you order? Please include CPT/Procedural codes for each.
- Referrals & Patient Education: Based on your patient’s given diagnosis, include referrals when applicable (if no referrals are necessary please state your reasons why and list pertinent patient education that is applicable to your diagnosis(s). Lastly, include return to clinical guidelines as part of your patient education.
- Prescriptions: Include written prescriptions of all medications that include prescriptions, OTC, (over the counter) and Herbal formulations; include teaching points with common potential side effects. Utilize the script padPreview the document for each medication.
- Summary: Explain how this paper met the purpose stated in the introduction.