SOAP NOTE: My stomach has been hurting for the past two days

For this week’s assignment you will analyze a SOAP note and complete your assignment based on the documentation provided below. The assignment this week should be completed in the format of a NARRATIVE PAPER to better explain your analysis.

Analyze the subjective portion of the note. List additional information that should be included in the documentation.

Analyze the objective portion of the note. List additional information that should be included in the documentation.

Is the assessment supported by the subjective and objective information? Why or why not?

What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

 

 

 

Below is the documentation you will use for your first assignment:

 

ABDOMINAL ASSESSMENT

 

Subjective:

 

CC: “My stomach has been hurting for the past two days.”

 

HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain.

 

PMH: HTN

 

Medications: Metoprolol 50mg

 

Allergies: NKDA

 

FH: HTN, Gerd, Hyperlipidemia

 

Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female

 

Objective:

 

VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lb

 

Heart: RRR, no murmurs

 

Lungs: CTA, chest wall symmetrical

 

Skin: Intact without lesions, no urticaria

 

Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound.

 

Diagnostics: US and CTA

 

Assessment:

 

Abdominal Aortic Aneurysm (AAA)

 

Perforated Ulcer

 

Pancreatitis

 

 

 

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

 

RUBRIC:

With regard to the SOAP note case study provided, address the following:

 

Analyze the subjective portion of the note. List additional information that should be included in the documentation.–

 

Excellent 10 (10%) – 12 (12%)

Good 7 (7%) – 9 (9%)

Fair 4 (4%) – 6 (6%)

Poor 0 (0%) – 3 (3%)

Analyze the objective portion of the note. List additional information that should be included in the documentation.–

 

Excellent 10 (10%) – 12 (12%)

Good 7 (7%) – 9 (9%)

Fair 4 (4%) – 6 (6%)

Poor 0 (0%) – 3 (3%)

Is the assessment supported by the subjective and objective information? Why or why not?–

 

Excellent 14 (14%) – 16 (16%)

Good 11 (11%) – 13 (13%)

Fair 8 (8%) – 10 (10%)

Poor 0 (0%) – 7 (7%)

What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?–

 

Excellent 18 (18%) – 20 (20%)

Good 15 (15%) – 17 (17%)

Fair 12 (12%) – 14 (14%)

Poor 0 (0%) – 11 (11%)

· Would you reject or accept the current diagnosis? Why or why not?

· Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.–

 

Excellent 23 (23%) – 25 (25%)

Good 20 (20%) – 22 (22%)

Fair 17 (17%) – 19 (19%)

Poor 0 (0%) – 16 (16%)

Written Expression and Formatting – Paragraph Development and Organization:

Paragraphs 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.–

 

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3 (3%) – 3 (3%)

Poor 0 (0%) – 2 (2%)

Written Expression and Formatting – English writing standards:

Correct grammar, mechanics, and proper punctuation–

 

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3 (3%) – 3 (3%)

Poor 0 (0%) – 2 (2%)

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.–

 

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3 (3%) – 3 (3%)

Poor 0 (0%) – 2 (2%)

Total Points: 100

 

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