Gastrointestinal Lab for Diagnosis|My homework helper

Posted: January 29th, 2023

WEEK 5 Lab for Diagnosis

Pick any “ADULT” Acute or Chronic Disease from Weeks 1-10 from your lecture class

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Week 2 EENT

Week 3 Dermatologic

Week 4 Cardiovascular

Week 5 Pulmonary

Week 6 Gastrointestinal

Week 7 Neuro

Week 9 Endocrine

Week 10 Musculoskeletal

Must use the sample template for your soap note, keep this template for when you start clinicals.

Templates used from another class will not be accepted. Students must use the template provided in this class which must clearly contain the progress note (in the Assessment section) of the encounter with the patient ( this section is clearly marked in bold, highlighted, and underlined). No passing grade will be granted if this section is not completed properly.

Follow the Soap Note Rubric as a guide.

Use APA format and must include a minimum of 2 Scholarly Citations within 5 years

The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment and Plan should be of your own work and individualized to your made-up patient.

Soap Note # _____ Main Diagnosis: Dx: Herpes Zoster


Name: Ms. GP

Age: 78

Gender at Birth: Female

Gender Identity: Female

Source: Patient

Allergies: Peanut. Iodine

Current Medications:

 Insulin Lantus 100 u/ml 15 unit in the morning and at bedtime

 Metformin 500 mg 1 tablet PO once a day

 Atorvastatin 20 mg 1 tablet PO at bedtime


 Diabetes mellitus type II

 Hyperlipidemia

 Varicella (Chickenpox) at the age of 20-year-old

Immunizations: Flu vaccine in 2020, Covid -19 (Pfizer) in 2021

Preventive Care: Wellness exam on 03/2021

Surgical History: appendicectomy 20 years ago

Family History: daughter 48 years old / hyperlipidemia

Social History: Patient is widow, and lives with her daughter. Catholic religion. No alcohol. No

smoker. No history of drug used, sedentary lifestyle. Does not work.

Sexual Orientation: Straight

Nutrition History: Regular diet, low in carbohydrates and fat.

Subjective Data:

Chief Complaint: I have been feeling itching and pain on my right lower back” started 3 days ago.

Symptom analysis/HPI: The patient is Ms. GP is 78-year-old Hispanic woman, who is complaining about itching, pain or tingling on her right lower back. Patient stated that 3 days ago she started to feel an increase in burning sensation on the area taking all right lower back and don’t relieve the pain with analgesic, she stated that wear any clothes that touch the area is very uncomfortable. Denies any episodes of fever but she feels fatigue and chills and mild headache. She stated that today in the morning she feel worse and noted some redness in the area and decided to come to the clinic to PCP evaluation.

Review of Systems (ROS)

CONSTITUTIONAL: fatigue, chills, denies weakness, no thirsty, no loss of weight. No fever.

NEUROLOGIC: mild headache, no dizziness, no changes in LOC, no loss of strength or

weakness/paresis/paralysis on extremities, no Hx of tremors or seizures.

HEENT: denies any head injury, denies any pain

Eyes: patient denies blurred vision, no diplopia, no wear glasses for reading

Ears: patient denies tinnitus, ear pain, no ear drainage through ear canal.

Nose: no presence of nasal obstruction, no nasal discharge, denies nasal bleeding. (No epistaxis)

Throat: no sore throat, no hoarse voice, no difficult to swallow

RESPIRATORY: patient denies shortness of breath, cough, expectoration, or hemoptysis.

CARDIOVASCULAR: patient denies chest pain, tachycardia. No orthopnea or paroxysmal nocturnal dyspnea.

GASTROINTESTINAL: patient denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea. (BM pattern) every other day, last BM: today, no rectal bleeding visible for her.

GENITOURINARY: patient denies polyuria, no dysuria, no burning urination, no hematuria, no lumbar pain, no urinary incontinence.

MUSCULOSKELETAL: denies falls or pain. Denies hearing a clicking or snapping sound

SKIN: patient states itching, pain, or tingling sensation on her right lower back.

HEMO/LYMPH/ENDOCRINE: glands swelling on groin, denies bruising or abnormal bleeding.

PSYCHIATRIST: patient denies anxiety, depression, denies hallucinations or delusions, no mood changes

Objective Data:


Temperature: 98.4 °F, Pulse: 82x ‘, BP: 122/71 mm hg, RR 19, PO2-97% on room air, Ht- 5’3”,

Wt 164 lb, BMI 30.2. Report pain 6/10.

GENERAL APPEARANCE: Adult, female. Alert and oriented x 3.

NEUROLOGIC: Alert, oriented to person, place, and time. Cranial nerves from I to XII intact. Sensation is intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. Pupil is normal in size and equal. Deep tendon reflex presents.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness.

Eyes: No conjunctival injection, no icterus, visual acuity, and extraocular eye movements intact. No nystagmus noted. Wear glasses.

Ears: BL external canal pattern, permeable, no redness, no drainage, tympanic membrane intact, pearly gray with sharp cone of light. No pain or edema noted.

Nose: Nasal mucosa normal. No irritations.

Mouth: oral mucosa pink, tongue central, papillaes normal distributed, no lesions detected, present of upper and lower denture, fitting properly. Lips with no lesions.

Neck: No lymphadenopathy noted. No jugular vein distention. No thyroid swelling or masses, no thrills on auscultation.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec. Peripheral pulses present and symmetric. No edema on BLE.

RESPIRATORY: Lungs sound clear. Chest wall symmetric and no deformities, no intercostal retractions, the patient no noticed dyspnea, no orthopnea. No egophony, no pectoriloquy, no fremitus or sign of condensation tissue on palpation. Resonance is equal in both hemithorax. Lungs: breath sounds present and clear on auscultation, no rales, no wheezing, no rhonchi.

GASTROINTESTINAL: Abdomen soft and non-tender. Continent to BB. Bowel sounds are present in all four quadrants; no bruits are present over the aortic or renal arteries. Last BM today.

GENITOURINARY: Costovertebral angles non-tenders, kidneys no palpable. External genitalia present, no enlargement, no tumors palpable. Groins area was noted with redness.

MUSCULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

INTEGUMENTARY: painful redness rash, with crops of vesicles on an erythematous base with a few satellite lesions in linear distribution, do not cross the midline, some of the blisters are filled with purulent fluids and others are crusted. The area is swollen and redness.


Patient Ms. GP isa 78-year-old Hispanic woman with Hx of DM Type II and Hyperlipidemia, came into our clinic today complaining about itching, pain and tingling on her right lower back starting 3 days ago. During the physical exam was noted painful redness rash, with crops of vesicles on an erythematous base with a few satellite lesions in linear distribution, which do not cross the midline. Diagnosis is based on the clinical evaluation through history and physical examination. According to patient’s presentation, signs and symptoms patient is diagnosed with herpes zoster. Patients falls into the high-risk group based on Buttaro (2017). Herpes zoster is viral infection that occurs with reactivation of the varicella-zoster virus and the patient referred has history of Chickenpox when she was 20 years old.

Main Diagnosis

Herpes Zoster (ICD10 B02.9): Herpes zoster is infection that results when varicella-zoster virus reactivates from its latent state in a posterior dorsal root ganglion. Symptoms usually begin with

pain along the affected dermatome, followed within 2 to 3 days by a vesicular eruption that is usually diagnostic. (Domino, Baldor, Golding, &Stephens,2017).

Other diagnosis:

Diabetes mellitus type II. (ICD-10 E11.9)

Hyperlipidemia. (ICD-10 E78.5)

Differential diagnosis

 Irritant contact dermatitis (ICD10 L24)

 Impetigo. (ICD10 L01.0)

 Varicella. (ICD 10 B01)

 Dermatitis herpetiformis. (ICD10 L13.0)


Labs and Diagnostic Test to be ordered (if applicable)

 Viral culture, polymerase chain reaction for VZV

Pharmacological treatment:

 Valtrex 1 gm TID x 7 days ideally during the prodrome, and is less likely to be effective if

given > 72 hours after skin lesions appear,

 VZV vaccine

 Pain-reliever NSAIDs

 Management of post herpetic neuralgia (Treatments include gabapentin, pregabalin)

Continue with current medication for chronic condition:

 Insulin Lantus 100 u/ml 15 unit in the morning and at bedtime

 Metformin 500 mg 1 tablet PO once a day

 Atorvastatin 20 mg 1 tablet PO at bedtime

Non-Pharmacologic treatment:

 Do not scratch the area with dirty hands. Use lotion like calamine to refresh the area.

 Keep the area clean and dry.


 Isolation precaution – Type Contact

 Avoid contact with susceptible person like pregnancy woman, kids and

Immunocompromised patient.

 Education about hand washing.

 Avoid ABT cream.


Follow up appointment 2 weeks / No referral needed at this time

Call if the symptoms are worse or you noticed any adverse reaction.



Buttaro, T. M., Trybulski, J. A., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care: a

collaborative practice. St. Louis, MO: Elsevier.

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017

(25th ed.). Print (The 5-Minute Consult Series).

McCance, K. L., & Huether, S. E. (2019). Pathophysiology: the biologic basis for disease in

adults and children. St. Louis, MO: Elsevie


A gastrointestinal (GI) lab is a medical facility that specializes in diagnosing and treating conditions and diseases of the digestive system, such as the esophagus, stomach, small intestine, colon, and rectum. Some common diagnostic tests that may be performed in a GI lab include colonoscopies, upper endoscopies, and stool tests. These tests can help identify issues such as ulcers, cancer, and infections, and are used to aid in developing a treatment plan for the patient.

The patient’s abdomen is soft and non-tender, meaning there is no pain or discomfort when touched or pressed. They are able to control their bowel movements and there are no audible sounds coming from blood vessels near the aorta or kidneys. The patient had a bowel movement today.

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