THE EPISODIC SOAP NOTE FOR THE ANALYSIS: ABDOMINAL ASSESSMENT
Assessing the Abdomen
In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.
To Prepare
Review the Episodic note case study your instructor provides you for this week’s Assignment. With regard to the Episodic note case study provided: (SEE BELOW)
o Review this week’s Learning Resources, and consider the insights they provide about the case study. (SEE ATTACHED LEARNING RESOURCES).
o Consider what history would be necessary to collect from the patient in the case study.
o Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
THE EPISODIC SOAP NOTE FOR THE ANALYSIS:
ABDOMINAL ASSESSMENT
Subjective:
• CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
• HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
• PMH: HTN, Diabetes, hx of GI bleed 4 years ago
• Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
• Allergies: NKDA
• FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
• VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
• Heart: RRR, no murmurs
• Lungs: CTA, chest wall symmetrical
• Skin: Intact without lesions, no urticaria
• Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
• Diagnostics Tests: None
DIAGNOSIS:
• Left lower quadrant pain
• Gastroenteritis
THE ASSIGNMENT TO BE COMPLETED (PLEASE INCLUDE SUBTITLES)
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
3. Is the assessment supported by the subjective and objective information? Why or why not?
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5. Would you reject/accept the current diagnosis? Why or why not?
6. Identify four possible conditions that may be considered as a differential diagnosis for this patient.
7. Explain your reasoning using at least four different references from current evidence-based literature within the last 5 years. (1 or 2 from learning resources and 2 or 3 from other credible sources).
ASSIGNMENT GRADING RUBRIC:
• The response must clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.
• The response must clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.
• The response must thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis. The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning.
• The response must clearly, thoroughly, and accurately identifies four conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three different references from current evidence-based literature. Written Expression and Formatting – Paragraph Development and Organization:
• Paragraphs must make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
• Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
• Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
Source
https://safehomework.com/subject-nursing/assessing-the-abdomen
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