PRAC 6531 Episodic Visit: Gastrointestinal Focused Note

Walden University PRAC 6531 Episodic Visit: Gastrointestinal Focused Note-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University PRAC 6531 Episodic Visit: Gastrointestinal Focused Note  assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for PRAC 6531 Episodic Visit: Gastrointestinal Focused Note                                                      

Whether one passes or fails an academic assignment such as the Walden University PRAC 6531 Episodic Visit: Gastrointestinal Focused Note   depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for PRAC 6531 Episodic Visit: Gastrointestinal Focused Note                                                    

The introduction for the Walden University PRAC 6531 Episodic Visit: Gastrointestinal Focused Note   is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for PRAC 6531 Episodic Visit: Gastrointestinal Focused Note                                                    

After the introduction, move into the main part of the PRAC 6531 Episodic Visit: Gastrointestinal Focused Note   assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for PRAC 6531 Episodic Visit: Gastrointestinal Focused Note                                                    

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for PRAC 6531 Episodic Visit: Gastrointestinal Focused Note                                                      

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for PRAC 6531 Episodic Visit: Gastrointestinal Focused Note

Episodic/Focus Note Template

Patient Information:

Initials: H.D.            Age: 48 years old               Sex: Male               Race: Hispanic

S.

CC: “Burning sensation in my chest”

HPI: Mr. H.D. is a 48-year-old Hispanic male with a medical history of hyperlipidemia, hypothyroidism, hypertension, and Type II diabetes mellitus. He is currently experiencing abdominal discomfort, which he rates at a 5 to 6 out of 10, for the past two days. The patient reports experiencing persistent stomach discomfort for the past two days. He describes the sensation as a burning pain that originates in the mid-abdomen and extends to the middle of the chest. The patient’s pain typically starts after eating and intensifies when reclined but improves upon walking. The patient reports no symptoms of constipation or diarrhea. The individual’s most recent meal occurred at 14:00 today. The patient said that he has recently begun a daily regimen of aspirin, following the recommendation of his primary care physician.:

Location: Abdomen/Chest

Onset: 2 days ago

Character: Burning pain that originates in the mid-abdomen and extends to the middle of the chest

Associated signs and symptoms: reports no symptoms of constipation or diarrhea.

Timing: starts after eating

Exacerbating/ relieving factors: intensifies when reclined but improves upon walking

Severity: 5-6/10 pain scale

Current Medications:

• Atorvastatin (Lipitor) 40 mg once daily, preferably at night.
• Daily 100 mcg levothyroxine (SYNTHROID).
• Metformin (GLUCOPHAGE) 500 mg tablet taken twice daily.
• Aspirin 81 milligrams once daily.

Allergies: No allergies reported

PMHx: The patient has a history of diabetes mellitus, which is being managed through a combination of diet and medication. He also has hyperlipidemia, for which he is currently taking medication. Additionally, he also has hypothyroidism, which is being managed through medication.

Soc Hx: The patient occasionally consumes ETOH, drinking 2-3 cans of beer twice per week. He denies using illegal drugs and smoking.

Fam Hx: The patient said that their father has hypertension and their mother has diabetes, and both parents are still living.

ROS:

GENERAL: The patient is agreeable and willing to cooperate. Describes moderate abdominal pain, rating it at 5-6 on a scale of 10. The patient does not appear to be in any immediate distress.

HEENT: denies experiencing a headache, sore throat, or hearing loss.

SKIN: Not itchy or rash.

CARDIOVASCULAR: He reportedly felt a burning feeling on his chest when lying down.

RESPIRATORY: Denies experiencing coughing or dyspnea.

GASTROINTESTINAL: Reports of 5–6/10 stomach pain throughout the last two days. Characterized as “scorching” and “gnawing.” denies feeling sick or throwing up. The bowel pattern is unchanged.

GENITOURINARY: Disputes hematuria or dysuria.

NEUROLOGICAL: Denies localized weakness or lack of feeling.

MUSCULOSKELETAL: Denies drooping of the face, swelling of the joints, or focal weakness.

HEMATOLOGIC: No bleeding, bruising, or anemia.

LYMPHATICS: No nodes are enlarged. Absence of cervical lymphadenopathy

PSYCHIATRIC: No prior experience with anxiety or despair.

ENDOCRINOLOGIC: No notes of perspiration or sensitivity to heat or cold. Neither polydipsia nor polyuria.

ALLERGIES: There is no history of rhinitis, eczema, asthma, or hives.

O.

Physical exam:

Vital signs: oral temperature 98.3F; RR 18; non-laborious; B/P 117/59; pulse 108 (strong and regular); SpO2: 96% in ambient air;1.575 m (5′ 2′′) in height and 73.5 kg (162 lb.) body weight.

General: A&O x4, kind and helpful. No severe discomfort.

HEENT: normal cranium and atraumatic. PERRLA: lack of conjunctival erythema, moist mucous membranes, red oropharynx, and anicteric sclera.

Neck: Flexible. Absent JVD. The median of the trachea. No perceptible nodules, edema, or discomfort.

Chest/Lungs: Both sides are clear to auscultate. No crackles, rhonchi, or wheezing. no utilization of auxiliary muscles.

Heart/Peripheral Vascular: Heart rhythm and rate are regular. Not a whisper. No palpitations. There is no bilateral peripheral edema to palpate.

ABD: Pain ratings of 5–6/10. Non-tender, non-distended, and soft. BS that is overactive. Inability to feel hepatosplenomegaly

Genital/Rectal: The bladder and bowel continent.

Musculoskeletal: Typical range of movement. appropriate muscular mass for age. No joint malformations or edema.

Neuro: Focused and aware x 4. Sensation and strength unaltered.

Lymph nodes/Skin: There is no cervical lymphadenopathy. Not even erythema or rashes. Absence of lesions.

Diagnostic results: Electrocardiogram (EKG) indicates normal sinus rhythm (NSR). Results from laboratory studies indicate the following: CBC – WBC count of 9.4, H/H ratio of 14.3/41.0, and PLT count of 289. The chemistry panel results are as follows: BUN/Crea ratio is 19/0.52, and the glucose level is 117*. The Pylori serology result is negative and awaiting the pending Esophageal pH Test.

A.

Differential Diagnoses:

1. Gastroesophageal Reflux Disease: GERD refers to the regurgitation of acidic stomach contents into the esophagus (Maret-Ouda et al., 2020). The patient presents with complaints of a searing, gnawing pain in the middle of the upper abdomen that intensifies while lying down. Based on the stated symptoms, alcohol intake, and recent changes in the patient’s medication, the primary diagnosis for the patient is GERD.
2. Acute coronary syndrome: can manifest as heartburn or a bitter taste in the mouth, often occurring after meals. GERD is a frequent culprit of non-cardiac chest pain (Bhatt et al., 2022).

1. Peptic Ulcer: Burning or gnawing pain is commonly reported with this condition, typically occurring on an empty stomach, during times of stress, or after alcohol consumption. This pain is alleviated by eating (Graham & Khalaf, 2019).
2. Achalasia: is a medical condition characterized by the inability of the esophagus to transport food to the stomach properly. This occurs when the lower esophageal sphincter remains closed during swallowing, causing food to back up. Common symptoms of achalasia include vomiting unprocessed food, chest pain, heartburn, and loss of weight (Savarino et al., 2022).
3. Gastritis: is characterized by a persistent burning pain in the epigastric area, often accompanied by symptoms such as nausea, vomiting, diarrhea, or fever. It has been observed that the consumption of alcohol, nonsteroidal inflammatory drugs, and salicylates can exacerbate the pain (Rugge et al., 2020).

It is necessary to order an upper GI endoscopy to assess potential complications of GERD or other underlying issues that may be contributing to the patient’s symptoms (Maret-Ouda et al., 2020).

The treatment involves lifestyle modification and controlling gastric acid secretion through medication or surgical treatment based on the lab results (Maret-Ouda et al., 2020).

If medication fails to alleviate the patient’s condition, a referral to a specialist may be made to explore the possibility of surgery (Maret-Ouda et al., 2020).

The patient will be instructed to elevate their head while sleeping. Utilizing additional pillows can aid in preventing reflux. Consuming smaller, more frequent meals throughout the day, rather than a few large ones, has been found to support digestion and potentially reduce the occurrence of heartburn (Maret-Ouda et al., 2020).

To assess the outcome, the patient should schedule a follow-up appointment at the clinic one week after treatment.

Reflection: The case scenario outlined above presents a patient displaying symptoms of burning pain that originates in the abdomen and extends to the middle of the chest. The individual characterizes the discomfort as a persistent sensation that commences following meals, particularly when in a reclined position. These symptoms align with the diagnosis of GERD, a condition frequently observed in individuals of lower socioeconomic status and advanced age who may face challenges in accessing nutritious foods. Additional diagnostic tests, such as GI endoscopy, must be conducted before medication therapy to confirm this diagnosis (Maret-Ouda et al., 2020). Meanwhile, patients can implement the recommended lifestyle changes and adopt appropriate dietary habits to manage symptoms effectively. These may include sleeping with an elevated head and consuming small, frequent meals. The patient’s case was presented and handled suitably.

References

Bhatt, D. L., Lopes, R. D., & Harrington, R. A. (2022). Diagnosis and treatment of acute coronary syndromes. JAMA, 327(7), 662. https://doi.org/10.1001/jama.2022.0358

Graham, D. Y., & Khalaf, N. (2019). Peptic ulcer disease. In Springer eBooks (pp. 1–31). https://doi.org/10.1007/978-3-319-90761-1_63-1

Maret-Ouda, J., Markar, S. R., & Lagergren, J. (2020). Gastroesophageal reflux disease. JAMA, 324(24), 2565. https://doi.org/10.1001/jama.2020.21573

Rugge, M., Sugano, K., Sacchi, D., Sbaraglia, M., & Malfertheiner, P. (2020). Gastritis: An update in 2020. Current Treatment Options in Gastroenterology, 18(3), 488–503. https://doi.org/10.1007/s11938-020-00298-8

Savarino, E., Bhatia, S., Gyawali, C. P., Sifrim, D., Tack, J., Thompson, S. K., & Gyawali, C. P. (2022). Achalasia. Nature Reviews Disease Primers, 8(1). https://doi.org/10.1038/s41572-022-00356-8

Sample Answer 2 for PRAC 6531 Episodic Visit: Gastrointestinal Focused Note

Patient Information:

Initials: D.D

Age: 32 years

Sex: Female

Race: African American

S.

CC (chief complaint): Stomach pain.

HPI: D.D. is a 32-year-old African American female client who visited the facility with complaints of stomach pain. She reported that the stomach pain had lasted the last three days. She described the stomach pain as a generalized non-radiating burning ache specific in the upper abdomen. She noted accompanying symptoms that included belching, nausea and vomiting, decreased appetite, and a feeling of fullness in her stomach. She reported using antacids, which provided short-term relief. The patient rated the abdominal pain at 5/10 on the pain scale.

Location: Upper abdomen

Onset: 3 days ago

Character: generalized non-radiating burning ache.

Associated signs and symptoms: belching, nausea and vomiting, decreased appetite, and bloating.

Timing: non-specific

Exacerbating/ relieving factors: None

Severity: 5/10 pain scale

Current Medications: OTC Antacids for stomach pain. OTC Motrin for period pain and headaches.

Allergies: No food, drug, or seasonal allergies.

PMHx: No history of chronic illnesses. History of Open reduction and internal fixation (ORIF) at 19 years following a femur fracture from an RTA. Immunization is current, with the last Flu shot being 5 months ago and TT 3 years ago.

Soc Hx: The patient is a high school teacher with a Bachelor’s degree in Education. She is married and has one son, who is four years old. Her hobbies are playing volleyball and baking. She coaches the volleyball team in the high school. She occasionally takes beer but denies smoking or using drugs substances.

Fam Hx: The maternal grandmother has diabetes and HTN. Her paternal grandfather died from lung cancer at 78 years old. Her parents and siblings are alive and well.

ROS:

GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: Negative for hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: Denies discoloration, rash, or itching.

CARDIOVASCULAR: Denies chest pain, palpitations, SOB, or edema.

RESPIRATORY: Denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: Positive for epigastric pain, belching, nausea, vomiting, decreased appetite, and bloating. Denies constipation, diarrhea, or tarry stools.

GENITOURINARY: Denies urinary urgency, frequency, pain during urination, or blood in urine.

NEUROLOGICAL: Denies excessive fatigue, dizziness, tingling sensations, and headaches.

MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, and stiffness.

HEMATOLOGIC: Denies anemia, bleeding, or bruising.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denies a history of depression or anxiety.

ENDOCRINOLOGIC: Denies acute thirst, excessive hunger, intolerance to heat or cold, and excessive sweating.

ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis.

O.

Physical exam:

Vital signs: T 98.6, RR 20, BP 120/78, P 60, SPO2 98%.

General: Female adult patient in no distress. She is appropriately dressed for the weather and neat. She is attentive, maintains eye contact, and is oriented to person, place, and time.

Cardiovascular: No cyanosis or pallor, jugular vein distension, or edema. S1 and S2 present, regular heart rhythm. S gallop sound absent. No bruits, heart murmurs, or friction rubs.

Respiratory: Respiration is effortless with no use of accessory muscles; Chest rises and falls uniformly on inspiration and expiration. On auscultation, respirations are regular and have a normal rhythm. Normal Broncho-vesicular breath sounds were present. Wheezing, rhonchi, grunting, crackles, and rales are absent.

Abdominal: On examination, bowel sounds were present and normoactive in all four quadrants, with no evidence of abdominal swelling or rebound tenderness.

Diagnostic results: Complete blood count (CBC) – Within normal limits.

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.

Primary Diagnosis- Gastritis (K29. 0): Gastritis is an inflammation of the gastric mucosa lining, which can be scattered or localized. Clinical manifestations of acute gastritis include nausea, vomiting, heartburn, anorexia, rapid onset of epigastric pain or discomfort, hematemesis, and gastric hemorrhage (Rugge et al., 2020). Patients with chronic gastritis present with nausea, vomiting, anorexia, vague reports of epigastric pain worsened by food, intolerance to fatty and spicy foods, and pernicious anemia (Shah et al., 2021). Acute gastritis was the primary diagnosis based on the patient’s report of epigastric pain, nausea, vomiting, and reduced appetite.

Helicobacter Pylori- Associated Active Gastritis (B96. 81): This is a primary infection of the stomach caused by Helicobacter pylori bacteria. Acute H.pylori infection results in a clinical syndrome marked by epigastric pain, nausea, vomiting, abdominal fullness, flatulence, and malaise (Pennelli et al., 2020). This differential is based on positive symptoms of epigastric pain, nausea, vomiting, and abdominal bloating.

Peptic Ulcer disease (PUD) (K27. 9): PUD occurs when there is a break in the mucous lining of the GI tract, and it comes into contact with HCL acid and pepsin, resulting in a gastric, duodenal, or esophageal ulcer. Abdominal pain is the classic symptom. It is described as burning, aching hunger-like in the epigastric region, possibly radiating to the back (Bereda, 2022). It occurs when the stomach is empty and relieved by food. Other symptoms are vomiting, nausea, constipation, or diarrhea. PUD is a differential based on the patient’s history of epigastric pain, nausea, and vomiting.

P.

Diagnostic studies: Esophagogastroduodenoscopy (EGD) via an endoscope with biopsy. This is the gold standard for diagnosing gastritis. It can also be used to confirm if the gastric ulcers have healed (Shah et al., 2021).

Therapeutic intervention: Oral omeprazole 20 mg once daily.

Education: Patient education focused on the risk factors for gastritis, like NSAID use, alcohol consumption, excessive caffeine intake, smoking, and corticosteroid use. The patient was educated that long-term NSAID use like Motrin has a high risk for acute gastritis (Cifuentes et al., 2022).

Referrals: Refer to a gastroenterologist if the case gets complicated.

Follow-up: The patient will be scheduled for a follow-up after four weeks. She will be asked about improvement in gastritis symptoms like epigastric pain or discomfort, nausea and vomiting, heartburn, and anorexia.

Reflection: I agree with the preceptor’s diagnosis of gastritis and treatment using Omeprazole. Omeprazole falls under Proton pump inhibitors (PPIs), which completely inhibit acid secretion and have a long duration of action. They are the most effective gastric acid blockers. I have learned that irritants like aspirin, NSAIDs, corticosteroids, alcohol, and caffeine cause acute gastritis. In a different case, I would request an H.pylori test since H.pylori infection causes gastritis. Health promotion should include advising the patient to reduce alcohol and caffeine consumption, like coffee and tea, to avoid triggering gastritis symptoms (Orgler et al., 2023). In addition, patients with gastritis should be advised to eat a well-balanced diet and quit smoking. She should be educated on stress management using complementary and alternative therapies, like relaxation and meditation techniques.

References

Bereda, G. (2022). Peptic Ulcer disease: definition, pathophysiology, and treatment. Journal of Biomedical and Biological Sciences, 1(2), 1–10.

Cifuentes, J. D. G., Sparkman, J., & Graham, D. Y. (2022). Management of upper gastrointestinal symptoms in patients with autoimmune gastritis. Current Opinion in Gastroenterology, 38(6), 600-606. https://doi.org/10.1097/MOG.0000000000000878

Orgler, E., Dabsch, S., Malfertheiner, P., & Schulz, C. (2023). Autoimmune Gastritis: Update and New Perspectives in Therapeutic Management. Current Treatment Options in Gastroenterology, 21(1), 64-77.

Pennelli, G., Grillo, F., Galuppini, F., Ingravallo, G., Pilozzi, E., Rugge, M., Fiocca, R., Fassan, M., & Mastracci, L. (2020). Gastritis: update on etiological features and histological practical approach. Pathologica, 112(3), 153–165. https://doi.org/10.32074/1591-951X-163

Rugge, M., Sugano, K., Sacchi, D., Sbaraglia, M., & Malfertheiner, P. (2020). Gastritis: An update in 2020. Current Treatment Options in Gastroenterology, 18, 488-503.

Shah, S. C., Piazuelo, M. B., Kuipers, E. J., & Li, D. (2021). AGA Clinical Practice Update on the Diagnosis and Management of Atrophic Gastritis: Expert Review. Gastroenterology, 161(4), 1325–1332.e7. https://doi.org/10.1053/j.gastro.2021.06.078