Abdominal Assessment Case Study
Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
- With regard to the Episodic note case study provided:
- Review this week’s Learning Resources, and consider the insights they provide about the case study.
- 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 fivepossible conditions that may be considered in a differential diagnosis for the
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patient.
SEE EPISODIC SOAP NOTE, BELOW
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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 262lbs
- 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.
***Please DO NOT recopy this SOAP note to your assignment for Submission.
THE ASSIGNMENT
- 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.
- This should be a paper with subheadings, please use subheadings below. This makes your papers a lot easier to read and ensures you are answering all the questions on the Rubric. Be sure to answer all information to receive maximum points.
Subjective Portion
Objective Portion
Assessment Supported
Rejection or Acceptance
Possible Conditions
This should be written as a narrative/paragraphs only!
DO NOT rewrite a SOAP note.
Tell me what’s wrong with the Episodic SOAP Note, by responding to the statements/questions above.
Abdominal Assessment Case Study RUBRIC:
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning OutcomeWith 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. |
|
12 pts | ||||
| This criterion is linked to a Learning OutcomeAnalyze the objective portion of the note. List additional information that should be included in the documentation. |
|
12 pts | ||||
| This criterion is linked to a Learning OutcomeIs the assessment supported by the subjective and objective information? Why or why not? |
|
16 pts | ||||
| This criterion is linked to a Learning OutcomeWhat diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome· 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. |
|
25 pts | ||||
| This criterion is linked to a Learning OutcomeWritten 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. |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeWritten 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. |
|
5 pts | ||||
| Total Points: 100 | ||||||
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