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.

By Day 7 of Week 6

You also have your midterm exam! 

Welcome to week 6! We have lots to do this week. You have a case assignment this week that is NOT a soap note. This is a paper. 

The Assignment 

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 afterward. 

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 

/
/objective

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. 

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. 

By Day 7 of Week 6 You also have your midterm exam! Exam: Week 6 Midterm Exam This exam is a test of your knowledge in preparation for your certification exam. No outside resources, including books, notes, websites, or any other type of resource, are to be used to complete this exam. You are expected to comply with Walden University’s Code of Conduct. This exam will be on topics covered in weeks 1, 2, 3, 4, 5, and 6. Prior to starting the exam, you should review all of your materials. This exam is timed with a limit of 2 hours for completion. When time is up, your exam will automatically submit. By Day 7 of Week 6 Assignment 2 is encouraged but optional. If you have any questions about this week or anything please let me know. Dr. Snell Posted by: Mariea Snell Posted to: NURS-6512N-40-Advanced Health Assessment-2021-Winter-QTR-Term-wks-1-thru-11-(11/29/2021-02/13/2022)-PT27

Week 6 SOAP Note Analysis

Analysis of Subjective Portion of SOAP Note

After reviewing the selected SOAP Note of Patient JR, a 47-year-old white man assessed for abdominal pain, I have determined that the provider should have collected additional history in the present history illness (PHI) with a specific focus on the pain using mnemonic SOCRATES. It is important to ask the patient about the site of the pain carefully, noting whether he uses a single finger or is more diffuse. Next is the origin by enquiring when it started together with whether the onset was sudden or gradual. Let the patient describe the character of the pain using terms like gripping, stabbing, or burning, amongst other times. After getting the character description, two other aspects of the pain are radiation and associations, meaning whether there is radiation, for example, towards the back and expounding on whether it is associated with other signs and symptoms. The provider should then narrow down on the time course, enquiring whether the pain is continuous or intermittent and probing the patient on the exacerbating factors like movement, food, position, or medication and what factors relieve the pain. Lastly, the provider should ask the patient about the severity of the pain using a scale of 1to 10, where 10 means the worst pain ever.

Besides assessing the positive pain of the lower left quadrant, another component of the subjective section that the provider should have focused on is making a systematic inquiry on the patient’s appetite questions on whether there are fever symptoms and whether the patient has experienced unexplained weight gain or loss. Other pertinent questions should touch on the bowels like when they were last emptied, ability to pass stool with ease, consistency of stool, and presence of blood, mucus, or melaena. Lastly, the provider should have enquired whether the patient has any urinary symptoms and recent changes in diet as the change could trigger diarrhea.

Analysis of Objective Portion of SOAP Note

A well-written SOAP note in the Objection section should include a run-through of a full list of symptoms from major systems taken in head-to-toe format. There should also have a physical examination of all the body systems. The provider should have included a general review of weight loss, appetite change, lumps, bumps, rashes, amongst others. Then HEENT for head, eyes, ears, nose, and throat. The cardiovascular, respiratory, gastrointestinal, genitourinary, and musculoskeletal systems. Additional systems are skin, neurologic, psychiatric, endocrine hematologic or lymphatic, and allergic or immunologic.

The objective section should also include a physical examination of the patient starting with the general condition of the patient, the vital signs before requesting the patient to adequately undress and then systematically examine the abdomen so that that there is an inspection, percussion, palpitation, and auscultation without forgetting to examine his testes and hernia orifices.

 Does subjective and objective information support the assessment? 

Both subject and objective information support the assessment. The patient’s primary complaint supports this viewpoint is diarrhea and lower left quadrant pain. These two and other accompanying symptoms are indicative of gastrointestinal causes. However, the provider should rule out that the symptoms are not related to the patient’s comorbidities of diabetes and hypertension. For example, the subjective information may suggest a cause of gastroenteritis, as do the objective information of a low-grade fever at 99.8

What diagnostic tests would be appropriate for this case?

Rapid stool test. The presence of rotavirus or norovirus can help diagnose viral gastroenteritis.

 Would you reject/accept the current diagnosis? 

I concur with the current diagnosis of gastroenteritis since the patient’s clinical manifestations include a low-grade fever, occasional muscle aches, nausea, vomiting, watery non-bloody diarrhea, and abdominal pain that diffuses towards the left lower quadrant (Schulmutz et al., 2017).

Identify three possible conditions that may be considered as a differential diagnosis for this patient

  1. Gastroenteritis (Confirmed)

The primary symptoms of gastroenteritis include diarrhea, where there is a minimum of three liquid or semi-liquid stool s every 24 hours accompanied by abdominal pain, nausea, and mild fever. Upon taking the patient’s complete history, and since the patient did not have a persistent fever or bloody stool, there was no need to order a stool study test, and gastroenteritis was confirmed (Cardemil et al., 2020).

  • Diverticulitis (Refuted)

Diverticulitis may, like gastroenteritis, present with nausea, vomiting, abdominal pain, and constipation. However, according to de Dios Díaz-Rosales et al. (2019), the former’s pain is constant and persistent, although it also occurs on the left lower side. It may also present on the lower side, but constipation was used to rule out its diagnosis.

  • Left Inguinal /Femoral hernia (Refuted)

The patient presents with nausea, vomiting, and rapid pulse with sudden worsening pain that could indicate a femoral hernia. However, this diagnosis was ruled out because there is a lump in the groin area and groin discomfort together with a change in skin color around the area (Goethals et al., 2018). As such, these symptoms were used to rule out femoral hernia diagnosis.

References

Cardemil, C. V., O’Leary, S. T., Beaty, B. L., Ivey, K., Lindley, M. C., Kempe, A., … & Hall, A. J. (2020). Primary care physician knowledge, attitudes, and diagnostic testing practices for norovirus and acute gastroenteritis. PloS one15(1), e0227890.

de Dios Díaz-Rosales, J., Salva, C. R., & Velázquez-Meraz, I. (2019). Right side diverticulitis, differential diagnosis of complicated appendicitis. Clinical case. Cirujano General41(3), 226-229.

Goethals, A., Azmat, C. E., & Adams, C. T. (2018). Femoral hernia.

Schmutz, C., Bless, P. J., Mäusezahl, D., Jost, M., & Mäusezahl-Feuz, M. (2017). Acute gastroenteritis in primary care: a longitudinal study in the Swiss Sentinel Surveillance Network, Sentinella. Infection45(6), 811-824.

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