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? Provide reference for using the diagnostic test
- 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.
You have an assignment which is to analyze the SOAP note given to you. Submit your assignment in a Word document. This should be written in a narrative format and not a SOAP note.
ABDOMINAL ASSESSMENT
Subjective:
- CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”
- HPI: KM, 43 yo WF, complains of having generalized abdominal pain that started 3 days ago. She has not taken any medications because she did not know what to take. She states the pain is a 5/10 today but has been as much as 9/10 when it first started. She 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, 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.