Walden NURS 6512 Week 6 Medical Surgical History
You will ANALYZE (DETAILED) a SOAP note case study Week_6 SOAP.pdf (case study can be found in Module 3, Week 6) that describes abnormal findings in patients seen in a clinical setting.
Please DO NOT re-copy the SOAP note over again or summarize it. You must
explain the note by using evidence-based sources.
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. Everything written needs to be detailed and explained. Please write this in Narrative and not SOAP note form.
Assignment 1: Lab Assignment: Assessing the Abdomen (this Case Study can be found in Wk 6 Module)
Your narrative should address:
Consider what additional 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 3 possible conditions that may be considered in a differential diagnosis for the patient.
Your SOAP note should have detailed:
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?
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 3 different references from current evidence-based literature.
Week 6: Assessment of the Abdomen and Gastrointestinal System
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 started3 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 10units 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: NoneAssessment:
• 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.