A soap note case study | NURS – 6512N | Walden University

  

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In this assignment, you will analyze a SOAP 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.

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 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, hyperctive 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.

To prepare:

With regard to the SOAP 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.

To complete:

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 

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