SOAP Note Case Study Analysis

SOAP Note Case Study Analysis

Assesment 1: Assessing the Abdomen
A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.

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

In this assignment, you will analyze a SOAP note case study that describes abnormal findings in patients seen in a clinical setting.SOAP Note Case Study Analysis. 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.SOAP Note Case Study Analysis. 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:

BUY A PLAGIARISM-FREE PAPER HERE

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:SOAP Note Case Study Analysis

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?SOAP Note Case Study Analysis
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
To complete:

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. SOAP Note Case Study Analysis.Explain your reasoning using at least 3 different references from current evidence based literature.

Rubric Detail

 

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Name: NURS_6512_Week_6_Assignment1_Rubric

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Excellent              Good     Fair         Poor

Quality of Work Submitted:

The extent of which work meets the assigned criteria and work reflects graduate level critical and analytic thinking.

27 (27%) - 30 (30%)

Assignment exceeds expectations. All topics are addressed with a minimum of 75% containing exceptional breadth and depth about each of the assignment topics.SOAP Note Case Study Analysis

24 (24%) - 26 (26%)

Assignment meets expectations. All topics are addressed with a minimum of 50% containing good breadth and depth about each of the assignment topics.

21 (21%) - 23 (23%)

Assignment meets most of the expectations. One required topic is either not addressed or inadequately addressed.

0 (0%) - 20 (20%)

Assignment superficially meets some of the expectations. Two or more required topics are either not addressed or inadequately addressed.

Assimilation and Synthesis of Ideas:

The extent to which the work reflects the student's ability to:

 

Understand and interpret the assignment's key concepts.

27 (27%) - 30 (30%)

Demonstrates the ability to critically appraise and intellectually explore key concepts.

24 (24%) - 26 (26%)

Demonstrates a clear understanding of key concepts.

21 (21%) - 23 (23%)

Shows some degree of understanding of key concepts.

0 (0%) - 20 (20%)

Shows a lack of understanding of key concepts, deviates from topics.

Assimilation and Synthesis of Ideas:SOAP Note Case Study Analysis

The extent to which the work reflects the student's ability to:

 

 

Apply and integrate material in course resources (i.e. video, required readings, and textbook) and credible outside resources.

18 (18%) - 20 (20%)

Demonstrates and applies exceptional support of major points and integrates 2 or more credible outside sources, in addition to 2-3 course resources to support point of view.

16 (16%) - 17 (17%)

Integrates specific information from 1 credible outside resource and 2-3 course resources to support major points and point of view.

14 (14%) - 15 (15%)

Minimally includes and integrates specific information from 2-3 resources to support major points and point of view.

0 (0%) - 13 (13%)

Includes and integrates specific information from 0 to 1 resource to support major points and point of view.

Written Expression and Formatting

 

Paragraph/Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused--neither long and rambling nor short and lacking substance.    SOAP Note Case Study Analysis

9 (9%) - 10 (10%)

Paragraphs/Sentences follow writing standards for structure, flow, continuity and clarity

8 (8%) - 8 (8%)

Paragraphs/sentences follow writing standards for structure, flow, continuity and clarity 80% of the time.

7 (7%) - 7 (7%)

Paragraphs/sentences follow writing standards for structure, flow, continuity and clarity 60%- 79% of the time.

0 (0%) - 6 (6%)

Paragraphs/sentences follow writing standards for structure, flow, continuity and clarity < 60% of the time.

Written Expression and Formatting

 

English writing standards: Correct grammar, mechanics, and proper punctuation.

5 (5%) - 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors.

3 (3%) - 4 (4%)

Contains a few (1-2) grammar, spelling, and punctuation errors.

2 (2%) - 2 (2%)

Contains several (3-4) grammar, spelling, and punctuation errors.

0 (0%) - 1 (1%)

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

Written Expression and Formatting

 

The assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed.

5 (5%) - 5 (5%)

Contains parenthetical/in-text citations and at least 3 evidenced based references are listed.

3 (3%) - 4 (4%)SOAP Note Case Study Analysis

Contains parenthetical/in-text citations and at least 2 evidenced based references are listed

2 (2%) - 2 (2%)

Contains parenthetical/in-text citations and at least 1 evidenced based reference is listed

0 (0%) - 1 (1%)

Contains no parenthetical/in-text citations and 0 evidenced based references listed.SOAP Note Case Study Analysis