Case study for Assignment
Patient is a 9-month-old female brought to the clinic today with chief complain of absence of stools in 4 days. Patient’s mother stated patient have not moved her bowels in the past four and she is crying more and refusing to eat or drink fluids. She also stated she felt a lump around patient’s rectum this morning when she was giving her bath. She stated patient had vomiting three times in the past 24hrs.
- Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
- 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 growth and development or 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 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?
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