The Assignment 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 ad

Below is the SOAP note that you will analyze for your assignment this week. Review the information given. You will not be writing a SOAP note this week. Instead, write in a narrative format and address the following questions:

· Consider what history would be necessary to collect from the patient in the case study.

· 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?

· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

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: None

Assessment:

• Left lower quadrant pain• Gastroenteritis

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

The Assignment

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? 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.

,

USW1.32487.202030 – NURS-6512N-17,Advanced Health Assessment.2019 Winter Qtr 11/25-02/16-PT27

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Running head: 1 HEALTH ASSESSMENT 1 Suspected Entry: 63% match Uploaded – wk6HealthAssessment.docx HEALTH ASSESSMENT 1 Source – Another student's paper Health Assessment Information HEALTH ASSESSMENT 1 Suspected Entry: 63% match Uploaded – wk6HealthAssessment.docx HEALTH ASSESSMENT 1 Source – Another student's paper Health Assessment Information Health Assessment Name Institutional Affiliation Health Assessment 2 In treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses (Ball, et al., 2015). Suspected Entry: 100% match Uploaded – wk6HealthAssessment.docx In treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses (Ball, et al., 2015) Source – Another student's paper In treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses (Ball, et al., 2015) 3 In the scenario given, the subjective portion could be more detailed by asking the patient more targeted questions about the pain they are experiencing. Suspected Entry: 75% match Uploaded – wk6HealthAssessment.docx In the scenario given, the subjective portion could be more detailed by asking the patient more targeted questions about the pain they are experiencing Source – Another student's paper However, in the case presented, the subjective portion could be more detailed with the use of more targeted questions about the pain they are experiencing 2 A good subjective history of present illness allows the practitioner to visualize what is going on with the patient before diagnostic testing is completed. Suspected Entry: 89% match Uploaded – wk6HealthAssessment.docx A good subjective history of present illness allows the practitioner to visualize what is going on with the patient before diagnostic testing is completed Source – Another student's paper A good subjective history of present illness allows the practitioner to visualize what is going on with the patient before diagnostic testing is completed (Dains, et al., 2016) The patient reports that the pain started 3 days ago. Suspected Entry: 100% match Uploaded – wk6HealthAssessment.docx The patient reports that the pain started 3 days ago Source – Another student's paper The patient reports that the pain started 3 days ago To inquire more about the onset of the pain, the patient should be asked, “How did the pain start? Suspected Entry: 100% match Uploaded – wk6HealthAssessment.docx To inquire more about the onset of the pain, the patient should be asked, “How did the pain start Source – Another student's paper To inquire more about the onset of the pain, the patient should be asked, “How did the pain start Did it start gradually or all of a sudden” as well as what the patient was doing when the pain occurred. Suspected Entry: 86% match Uploaded – wk6HealthAssessment.docx Did it start gradually or all of a sudden” as well as what the patient was doing when the pain occurred Source – Another student's paper Did it start gradually or all of a sudden” as well as what the patient was doing when the pain occurred (Dains, et al., 2016) The quality of pain needs to be investigated as well. Suspected Entry: 100% match Uploaded – wk6HealthAssessment.docx The quality of pain needs to be investigated as well Source – Another student's paper The quality of pain needs to be investigated as well For example, colicky pain is often associated with forceful peristaltic contractions where as a poorly localized ache is associated with visceral peritonitis. Suspected Entry: 85% match Uploaded – wk6HealthAssessment.docx For example, colicky pain is often associated with forceful peristaltic contractions where as a poorly localized ache is associated with visceral peritonitis Source – Another student's paper For example, colicky pain is often associated with forceful peristaltic contractions whereas a poorly localized ache is associated with visceral peritonitis (Dains, et al., 2016) In cases of abdominal pain, it is important to ask the patient about their bowel movements. Suspected Entry: 83% match Uploaded – wk6HealthAssessment.docx In cases of abdominal pain, it is important to ask the patient about their bowel movements Source – Another student's paper In cases of abdominal pain, it is important to ask the patient about their bowel movements (Dains, et al., 2016) The characteristic, frequency, consistency, color and smell of the bowel movement can all be indicators of what processes are going on in the bowel (Ball, et al., 2015). Suspected Entry: 99% match Uploaded – wk6HealthAssessment.docx The characteristic, frequency, consistency, color and smell of the bowel movement can all be indicators of what processes are going on in the bowel (Ball, et al., 2015) Source – Another student's paper The characteristic, frequency, consistency, color and smell of the bowel movement can all be indicators of what processes are going on in the bowel (Ball, et al., 2015) For example, frequent, loose, strong smelling diarrhoea is associated with Helicobacter pylori, which would signal the practitioner to order stool testing to test for the bacterium. Suspected Entry: 83% match Uploaded – wk6HealthAssessment.docx For example, frequent, loose, strong smelling diarrhoea is associated with Helicobacter pylori, which would signal the practitioner to order stool testing to test for the bacterium Source – Another student's paper For example, frequent, loose, strong smelling diarrhea is associated with Helicobacter pylori (H.Pylori), which would signal the practitioner to order stool testing to test for the bacterium (Ball, et al., 2015) Inquiring more about the patient’s history with GI bleed would also help with understanding what procedures and GI tract disorders that the patient has had (Dains, et al., 2016). Suspected Entry: 99% match Uploaded – wk6HealthAssessment.docx Inquiring more about the patient’s history with GI bleed would also help with understanding what procedures and GI tract disorders that the patient has had (Dains, et al., 2016) Source – Another student's paper Inquiring more about the patient’s history with GI bleed would also help with understanding what procedures and GI tract disorders that the patient has had (Dains, et al., 2016) The objective assessment in the scenario is adequate, with positive findings in the abdominal assessment only. Suspected Entry: 100% match Uploaded – wk6HealthAssessment.docx The objective assessment in the scenario is adequate, with positive findings in the abdominal assessment only Source – Another student's paper The objective assessment in the scenario is adequate, with positive findings in the abdominal assessment only However, including assessments such as if the abdomen is distended by percussing the abdomen and measuring abdominal girth could be helpful to confirm if the abdomen is enlarged (Ball, et al., 2015). Suspected Entry: 99% match Uploaded – wk6HealthAssessment.docx However, including assessments such as if the abdomen is distended by percussing the abdomen and measuring abdominal girth could be helpful to confirm if the abdomen is enlarged (Ball, et al., 2015) Source – Another student's paper However, including assessments such as if the abdomen is distended by percussing the abdomen and measuring abdominal girth could be helpful to confirm if the abdomen is enlarged (Ball, et al., 2015) 4 The assessment is supported by the subjective information given. Suspected Entry: 100% match Uploaded – wk6HealthAssessment.docx The assessment is supported by the subjective information given Source – Another student's paper The assessment is supported by the subjective information given The patient’s heartrate, blood pressure and temperature are mildly elevated, due to the 5/10 pain the patient is experiencing during the assessment. Suspected Entry: 100% match Uploaded – wk6HealthAssessment.docx The patient’s heartrate, blood pressure and temperature are mildly elevated, due to the 5/10 pain the patient is experiencing during the assessment Source – Another student's paper The patient’s heartrate, blood pressure and temperature are mildly elevated, due to the 5/10 pain the patient is experiencing during the assessment 2 The hyperactive bowel sounds correlate with the patient stating that they are having diarrhoea. Suspected Entry: 74% match Uploaded – wk6HealthAssessment.docx The hyperactive bowel sounds correlate with the patient stating that they are having diarrhoea Source – Another student's paper The hyperactive bowel sounds correlate with the patient stating that they are having diarrhea (Dains, et al., 2016) The tenderness in the left lower quadrant (LLQ) is different from the generalized pain that the patient described, but the left lower quadrant could be the focal point of pain with referred pain in the other quadrants that are non-tender (Dains, et al., 2016). Suspected Entry: 100% match Uploaded – wk6HealthAssessment.docx The tenderness in the left lower quadrant (LLQ) is different from the generalized pain that the patient described, but the left lower quadrant could be the focal point of pain with referred pain in the other quadrants that are non-tender (Dains, et al., 2016) Source – Another student's paper The tenderness in the left lower quadrant (LLQ) is different from the generalized pain that the patient described, but the left lower quadrant could be the focal point of pain with referred pain in the other quadrants that are non-tender (Dains, et al., 2016) On collecting diagnostic data, I would start off by ordering a series of lab tests to rule out possible infection, electrolyte imbalances or parasitic infections that could be causing the pain. Suspected Entry: 99% match Uploaded – wk6HealthAssessment.docx On collecting diagnostic data, I would start off by ordering a series of lab tests to rule out possible infection, electrolyte imbalances or parasitic infections that could be causing the pain Source – Another student's paper On collecting diagnostic data, I would start off by ordering a series of lab tests to rule out possible infection, electrolyte imbalances or parasitic infections that could be causing the pain These would include a complete blood count (CBC), complete metabolic panel (CMP), Magnesium, Phosphate, occult stool and clostridium difficle stool (C.Diff) (Leblond, et al., 2014). Suspected Entry: 99% match Uploaded – wk6HealthAssessment.docx These would include a complete blood count (CBC), complete metabolic panel (CMP), Magnesium, Phosphate, occult stool and clostridium difficle stool (C.Diff) (Leblond, et al., 2014) Source – Another student's paper These would include a complete blood count (CBC), complete metabolic panel (CMP), Magnesium, Phosphate, occult stool and clostridium difficle stool (C.Diff) (Leblond, et al., 2014) A high white count result from the CBC would indicate there is an infective process going on somewhere in the body and would require more diagnostic testing into the source of the infection (Leblond, et al., 2014). Suspected Entry: 100% match Uploaded – wk6HealthAssessment.docx A high white count result from the CBC would indicate there is an infective process going on somewhere in the body and would require more diagnostic testing into the source of the infection (Leblond, et al., 2014) Source – Another student's paper A high white count result from the CBC would indicate there is an infective process going on somewhere in the body and would require more diagnostic testing into the source of the infection (Leblond, et al., 2014) The CMP would show liver, kidney and electroly

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