A male went to the emergency room for severe midepigastric abdominal pain. He was diagnosed with AAA ; however, as a precaution, the doctor ordered a CTA scan.

Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen.

In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. 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. Soap Note Analysis Essay Paper

To Prepare
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 five possible conditions that may be considered in a differential diagnosis for the patient.
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. Soap Note Analysis Essay Paper

Welcome to Week 6. This week, you have two assignments for grading, the midterm exam, and an analysis of a SOAP note. The SOAP note has been provided below. In the past, it has been easier for students to write the analysis in narrative form. However, I have had students use the SOAP format and include the missing data. Either way is fine if you have the required information. Please use the rubric for guidance to make sure you have everything that is required. This is what I will use for grading.

The next assignment is the midterm exam. The midterm exam is due by Day 7. If you did not access the exam review guide in Week 5, you can find it in the “Resources” section for this week. Per Walden’s policy, no outside resources including books, notes, websites, or any other type of resource are to be used to complete this exam. Students are expected to comply with Walden University’s Code of Conduct. The exam will be on topics covered in weeks 1, 2, 3, 4, 5, and 6. The exam is timed with a limit of two hours for completion. When time is up, the exam will automatically submit.

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There is also Abdominal Lab assignment is Shadow Health that must be completed. I am in the process of finishing up Week 4 grades. Since tomorrow is a holiday, I will allow one extra day to turn in Week 6 assignment. If you have any questions, please feel free to reach out to me.

Have a great week!

Dr. Benefield

ABDOMINAL ASSESSMENT Case Study

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.  Soap Note Analysis Essay Paper

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.

Soap Note Analysis

Subjective Portion Analysis

In the subjective part of the note, there is a dearth of vital information that contributes to an appropriate diagnosis. As such, additional information that should be included includes:

• Characteristics the pain
• Severity of the pain
• Whether it is constant or progressive pain
• What relieves or aggravates the pain
• Whether any medication has been taken within the past week

Objective Portion Analysis

There are critical things missing from the soap note when it comes to the objective information. Additional information that should be included in this section includes:

• Overall appearance of the patient
• Patient’s level of consciousness
• Findings of any laboratory tests performed
• Color of the patient’s skin

Is the assessment supported by subjective and objective information?

Both the subjective and the objective facts provide credence to the assessment. The patient has a history of experiencing stomach discomfort that has gradually become worse over time, along with vomiting. In addition, he expresses discomfort in the epigastric area as well as guarding, all of which are consistent with the presence of abdominal pain.  Soap Note Analysis Essay Paper

 Appropriate Diagnostic Tests

Diagnostic tests that will be required for this patient include:

• Complete blood count- to determine the presence of infection and bleeding,
• Chest/abdominal X-ray- to check for perforated ulcer.
• Abdominal ultrasonography- to determine the presence of abdominal aortic aneurysms, perforated ulcers, and other abdominal issues
• Amylase and lipase tests- to determine the presence of pancreatitis
• Abdominal CT scan- to check for abnormalities in the abdominal region
  

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 Reject/Accept the Current Diagnosis

The diagnosis of acute pancreatitis is reasonable to me; however the diagnoses of abdominal aortic aneurysm and perforated ulcer are not. Discomfort in the abdominal region, leg pain, and a pulsing abdomen are the signs of an abdominal aortic aneurysm, none of which are present in patient LZ. On the other hand, it is not possible for a perforated ulcer to cause discomfort in the back.

Three Possible Conditions

• Acute Pancreatitis:The quick onset of pancreatic inflammation is what’s meant to be understood by the term “acute pancreatitis” (Mederos et al., 2021). Abdominal discomfort is the most typical symptom of the condition.
• Gastritis: The term “gastritis” may apply to a number of different conditions, all of which are characterized by inflammation of the lining of the stomach (Azer et al., 2019). Vomiting, nausea, and upper stomach discomfort are among the symptoms of this condition.
• Cholecystitis:Cholecystitis is an inflammation of the gallbladder, which may be caused by a number of different conditions. This illness may manifest itself in a variety of ways, including discomfort in the right upper abdomen region, soreness in the right shoulder, vomiting, and nausea (Balmadrid, 2018).

References

Azer, S. A., & Akhondi, H. (2019). Gastritis. https://europepmc.org/article/nbk/nbk544250

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). Seidel’s Guide to

Balmadrid, B. (2018). Recent advances in management of acalculous cholecystitis. F1000Research, 7, 1660. https://doi.org/10.12688/f1000research.14886.1

Mederos, M. A., Reber, H. A., & Girgis, M. D. (2021). Acute pancreatitis. JAMA, 325(4), 382. https://doi.org/10.1001/jama.2020.20317

Soap Note Analysis Essay Paper