Abdominal Assessment Essay Assignment Paper

Abdominal Assessment Essay Assignment Paper

Soap Note Analysis

Subjective Portion Analysis

Appropriate clinical diagnosis and the development of personalized treatment plans for specific patients need a rigorous healthcare assessment. As such, more information on the nature of patient LZ’s pain is needed.  What are the characteristics and severity of the client’s pain? What triggered the onset of the pain? Was it progressive pain, or did he suddenly feel the effects of the pain? This necessitates a thorough examination of the patient’s symptoms to determine what kind of pain he is experiencing (Ball et al., 2017). It is important for the practitioner to get further information about the conditions that have caused the pain to increase or intensify. Other questions that a clinician should ask include: How would you rank your current level of pain? What is the highest number on a scale of one to ten? Is there any medicine you’ve taken in the last week? Have you had any surgical procedures performed on you? Do you experience greater pain when you are lying down than when you are sitting upright? Abdominal Assessment Essay Assignment Paper

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Objective Portion Analysis

There are critical things missing from the soap note when it comes to objective information. The overall appearance of the client must be described in the objective component of the note.  It is also necessary to record the patient’s level of consciousness. The findings of any laboratory tests performed, such as abdominal ultrasound and CT scan should be documented. Apart from the vital signs, heart, lungs, skin, and abdomen evaluation, the practitioner should additionally incorporate the client’s facial expression while assessing his painful area, the color of his skin, abdominal bloating, and whether or not he has excessive sweating.

 Is the assessment supported by subjective and objective information?

The assessment is supported by subjective and objective data. The patient has a history of abdominal pain that has become more severe over time, and he has also vomited. Furthermore, he reports pain in the epigastric region and guarding, which is in line with abdominal pain. Diagnostic tests such as the ultrasound and CT scan might provide additional findings to corroborate the assessment.

 Appropriate Diagnostic Tests

In order to determine the presence of infection and bleeding, a complete blood count will be required. Amylase and lipase tests are also required since a high lipase level in the presence of a normal amylase level indicates that pancreatitis is unlikely to be the cause. Abdominal ultrasonography is the most often used diagnostic to identify abdominal aortic aneurysms, perforated ulcers, and other abdominal abnormalities. It will also be essential to perform an abdominal CT scan, which is a non-invasive examination that employs X-rays to make cross-sectional pictures of the components within the abdominal region. An endoscopy will be performed to evaluate the upper digestive tract, and an abdominal/chest X-ray will be taken since air beneath the diaphragm may indicate a perforated ulcer Abdominal Assessment Essay Assignment Paper

 Reject/Accept the Current Diagnosis

I accept the diagnosis of acute pancreatitis; however, I disagree with the diagnoses of abdominal aortic aneurysm and perforated ulcer. The symptoms of an abdominal aortic aneurysm include abdominal pain, leg pain, and a pulsating belly. However, these indications are not apparent in this case, and as a result, I reject this diagnosis. I also reject the diagnosis of a perforated ulcer since the pain linked with this condition does not spread to the back.

 

Three Possible Conditions

• Acute Pancreatitis: Acute pancreatitis is defined as pancreatic inflammation that occurs suddenly (Mederos et al., 2021). The most common symptom is abdominal pain. It normally subsides after a few days, although it may often become serious and life-threatening. Gallstones and excessive alcohol use are the two most prevalent causes of acute pancreatitis.
• Cholecystitis: Cholecystitis is a condition in which the gallbladder becomes inflamed. It is often caused by gallstones obstructing the tube coming from the gallbladder. This leads to an accumulation of bile, which might result in inflammation. Some of the other possible causes of cholecystitis include abnormalities with the bile ducts or tumors, as well as an acute disease and some infections (Balmadrid, 2018). Right upper abdominal pain, soreness in the right shoulder, vomiting, nausea, and, on rare occasions, fever are all symptoms of this condition. Prescription painkillers (PPIs) do not alleviate the pain.
• Gastritis: Gastritis is a term that refers to a range of illnesses that are characterized by inflammation of the stomach’s lining. Gastritis is most commonly caused by infection with the same bacteria that cause most gastrointestinal ulcers, or by the persistent use of certain pain medications such as aspirin. Upper stomach pain, vomiting, and nausea are some of the symptoms. Symptoms may not appear at all in other cases Abdominal Assessment Essay Assignment Paper
  

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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

Assignment 1-Accessing the Abdomen

This week, you will complete an analysis of the SOAP note provided below. Write this up as a narrative so that you are able to correctly explain your analysis. You will not need to summarize the patient case, or create any additional information that is not listed, but to address the questions listed in the assignment.

Assignment 1-Accessing the Abdomen

To Prepare

Review the Episodic note case study provided below for this week’s Assignment.

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? Abdominal Assessment Essay Assignment Paper

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. This means differential diagnosis related to abdominal pain.

 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.

To Prepare

Review the Episodic note case study provided below for this week’s Assignment.

Regarding 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? Abdominal Assessment Essay Assignment Paper

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. This means differential diagnosis related to abdominal pain.

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.

Week 6: Assessment of the Abdomen and Gastrointestinal System (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. Abdominal Assessment Essay Assignment Paper

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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

 Rubric

Regarding the SOAP note case study provided, address the following:

Analyze the subjective portion of the note. List additional information that should be included in the documentation. — Abdominal Assessment Essay Assignment Paper

Excellent 10 (10%) – 12 (12%)

Good 7 (7%) – 9 (9%)

Fair 4 (4%) – 6 (6%)

Poor 0 (0%) – 3 (3%)

Analyze the objective portion of the note. List additional information that should be included in the documentation. —

Excellent 10 (10%) – 12 (12%)

Good 7 (7%) – 9 (9%)

Fair 4 (4%) – 6 (6%)

Poor 0 (0%) – 3 (3%)

Is the assessment supported by the subjective and objective information? Why or why not?–

Excellent 14 (14%) – 16 (16%)

Good 11 (11%) – 13 (13%)

Fair 8 (8%) – 10 (10%)

Poor 0 (0%) – 7 (7%)

What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?–

Excellent 18 (18%) – 20 (20%)

Good 15 (15%) – 17 (17%)

Fair 12 (12%) – 14 (14%)

Poor 0 (0%) – 11 (11%)

• Would you reject or 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. —

Excellent 23 (23%) – 25 (25%)

Good 20 (20%) – 22 (22%)

Fair 17 (17%) – 19 (19%)

Poor 0 (0%) – 16 (16%)

Written Expression and Formatting – Paragraph Development and Organization:

Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.– Abdominal Assessment Essay Assignment Paper

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3 (3%) – 3 (3%)

Poor 0 (0%) – 2 (2%)

Written Expression and Formatting – English writing standards:

Correct grammar, mechanics, and proper punctuation–

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3 (3%) – 3 (3%)

Poor 0 (0%) – 2 (2%)

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.–

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3 (3%) – 3 (3%)

Poor 0 (0%) – 2 (2%)

Total Points: 100

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 Abdominal Assessment Essay Assignment Paper