Soap Note Analysis Assignment Discussion Paper

Soap Note Analysis Assignment Discussion Paper

Subjective Portion Analysis

A thorough healthcare evaluation is essential for proper clinical diagnosis and the formulation of tailored therapeutic approaches for individual patients. Following a review of the subjective section of Patient LZ’s data, it was discovered that there are critical missing aspects that must be included in order to ensure efficient thoroughness and accurate diagnosis (Ball et al., 2017). The client claims that his abdomen aches, but further details regarding the nature of the discomfort are required. When it comes to the client’s pain, what are the features and intensity of the pain? How did the pain begin? Was it an ache that came on gradually, or did it hit him all at once? As a result, the clinician must inquire about the nature of the pain, including if it is severe, mild, throbbing, cramping, or dull (Ball et al., 2017). Additional information on the circumstances that cause the pain to worsen or escalate should be obtained by the clinician. Is the pain worse while he is lying down or moving about, or when he is eating or merely bending? Obtaining more details on the client’s bowel habits, such as regularity, color, and consistency is critical for determining the root causes of any symptoms the client exhibits Soap Note Analysis Assignment Discussion Paper.

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Objective Portion Analysis

In order to produce an appropriate diagnosis, objective data about the client must be combined with subjective data from the client’s records. This is why objective data is so important. There is a need for the practitioner to collect information on the client’s outward image, including if he is calm and whether he is pleasant. Persons suffering from abdominal discomfort, according to Dunlap and Patterson (2020), choose to lie motionless rather than move. Aside from that, those who come with epigastric abdominal pain are often uncomfortable and restless. The color of the abdomen area must also be assessed by the practitioner since the existence of a Cullen sign could suggest intraperitoneal hemorrhage, which signifies pancreatitis (Sullivan, 2019)Soap Note Analysis Assignment Discussion Paper. Since asymmetrical abdominal protrusion or distention may be associated with hernias, tumors, blockage of the intestine, or cysts, the medical practitioner should additionally examine the client for abdominal distention.

Is the assessment supported by subjective and objective information?

The data provided both objective and subjective, back up the assessment. The client complains of epigastric abdominal pain that becomes worse, and he also experiences guarding. The client’s history of high blood pressure, which is a risk variable for abdominal aortic aneurysms, also lends credence to the assessment. Pancreatitis is corroborated by an acute onset of pain that lasted 2 days and pain that spreads into his back Soap Note Analysis Assignment Discussion Paper.

Appropriate Diagnostic Tests

To accurately determine the source of the pain and eliminate any concerns, I would request various laboratory testing. A CT scan and an ultrasound are among the diagnostic procedures that might be useful in this case. Diagnosis would be made based on the findings of these procedures. Abdominal aortic aneurysms (AAAs) and perforated ulcers may be detected with a CT scan. It would be necessary to utilize ultrasound to detect pancreatitis.

Reject/Accept the Current Diagnosis

It is appropriate to utilize the current diagnoses since the client is experiencing stomach discomfort that has been more severe over the past few hours and has vomited. It is also possible that the client has an abdominal aortic aneurysm because of his history of high blood pressure, which is a known risk factor. The presence of gastroesophageal reflux disease (GERD) in the patient’s family history, which is a risk variable for perforated ulcers, further reinforces the diagnosis. The pancreatitis diagnosis is additionally bolstered by the fact that the client has a smoking history, which has been associated with pancreatic irritation Soap Note Analysis Assignment Discussion Paper.

Three Possible Conditions

• Acute Pancreatitis:Acute pancreatitis (AP) is an inflammation of the pancreas. It manifests itself abruptly and produces discomfort in the upper abdomen (or epigastric) area. The pain usually spreads to the back. The signs and symptoms of acute pancreatitis might be quite different from one person to another. Epigastric pain, stomach pain that spreads to the back, fever, fast heart rate, vomiting, and nausea are all indications and symptoms of acute pancreatitis (Mederos et al., 2021).
• Abdominal Aortic Aneurysm:An abdominal aortic aneurysm is a bulge in the lower section of the primary blood artery that provides blood to the body (aorta). It is hard to detect abdominal aortic aneurysms since they develop gradually and without causing any symptoms (Golledge, 2018). Some aneurysms do not rupture at all. Many of them start off small and remain that way. Others continue to increase in size over time, often at a rapid pace. An ache in the abdomen region that is deep and consistent, back pain, and a pulse at the belly button are all indications of an Abdominal Aortic Aneurysm.
• Perforated Ulcer:Untreated ulcers in the gut or colon may lead to perforation of the mucosal wall, enabling gastric fluids to flow into the abdominal wall, which is known as a perforated ulcer. Patients with perforated ulcers often complain of intense, sharp abdominal pain that develops all of a sudden (Chung & Shelat, 2017). The majority of patients complain of generalized pain, but a small number of patients complain of severe epigastric discomfort. Individuals with this condition adopt the fetal posture since even the slightest movement might significantly aggravate their pain Soap Note Analysis Assignment Discussion Paper.
  

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References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). Seidel’s Guide to Physical Examination-E-Book: An Interprofessional Approach. Elsevier Health Sciences.

Chung, K. T., & Shelat, V. G. (2017). Perforated peptic ulcer – an update. World Journal of Gastrointestinal Surgery, 9(1), 1. https://doi.org/10.4240/wjgs.v9.i1.1

Dunlap, J. J., & Patterson, S. (2020). Assessing abdominal pain. Gastroenterology Nursing, 43(3), 267-270. https://doi.org/10.1097/sga.0000000000000531

Golledge, J. (2018). Abdominal aortic aneurysm: Update on pathogenesis and medical treatments. Nature Reviews Cardiology, 16(4), 225-242. https://doi.org/10.1038/s41569-018-0114-9

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

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis. https://www.fadavis.com/product/physician-assistant-guide-to-clinical-documentation-sullivan-3 Soap Note Analysis Assignment Discussion Paper

ABDOMINAL ASSESSMENT 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. 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 coursesAssignment 1: Lab Assignment: Assessing the Abdomen Photo Credit: Getty Images/Hero Images 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. 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 Soap Note Analysis Assignment Discussion Paper.

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. By Day 7 of Week 6 Submit your Lab Assignment. Submission and Grading Information.Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Chapter 6, “Vital Signs and Pain Assessment” This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment. Chapter 18, “Abdomen” In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment of the abdomen. Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center. Chapter 3, “Abdominal Pain” This chapter outlines how to collect a focused history on abdominal pain. This is followed by what to look for in a physical examination in order to make an accurate diagnosis. Chapter 10, “Constipation” The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests. Chapter 12, “Diarrhea” In this chapter, the authors focus on diagnosing the cause of diarrhea Soap Note Analysis Assignment Discussion Paper.

The chapter includes questions to ask patients about the condition, things to look for in a physical exam, and suggested laboratory or diagnostic studies to perform. Chapter 29, “Rectal Pain, Itching, and Bleeding” This chapter focuses on how to diagnose rectal bleeding and pain. It includes a table containing possible diagnoses, the accompanying physical signs, and suggested diagnostic studies. Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis. Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center. These sections below explain the procedural knowledge needed to perform gastrointestinal procedures. Chapter 115, “X-Ray Interpretation of Abdomen” (pp. 514–520) Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Chabok, A., Thorisson, A., Nikberg, M., Schultz, J. K., & Sallinen, V. (2021). Changing paradigms in the management of acute uncomplicated diverticulitis. Scandinavian Journal of Surgery, 110(2), 180–186. https://doi.org/10.1177/14574969211011032 Hussein, A., Arena, A., Yu, C., Cirilli, A., & Kurkowski, E. (2021). Abdominal pain in the elderly patient: Point-of-care ultrasound diagnosis of small bowel obstruction. Clinical Practice and Cases in Emergency Medicine, 5(1), 127–128. https://doi.org/10.5811/cpcem.2020.11.50029 Document: Midterm Exam Review (Word document) Optional Resource LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical. Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” This chapter explores the health assessment processes for the abdomen, perineum, anus, and rectosigmoid. This chapter also examines the symptoms of many conditions in these areas. Chapter 10, “The Urinary System” In this chapter, the authors provide an overview of the physiology of the urinary system. The chapter also lists symptoms and conditions of the urinary system.Rubric Detail Select Grid View or List View to change the rubric’s layout. Name: Soap Note Analysis Assignment Discussion Paper

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NURS_6512_Week_6_Assignment_1_Rubric Grid View List View Excellent Good Fair Poor With regard to 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. 10 (10%) – 12 (12%) The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation. 7 (7%) – 9 (9%) The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation. 4 (4%) – 6 (6%) The response vaguely and/or with some inaccuracy analyzes the subjective portion of the SOAP note and vaguely and/or with some inaccuracy lists additional information to be included in the documentation. 0 (0%) – 3 (3%) The response inaccurately analyzes or is missing analysis of the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation. Analyze the objective portion of the note. List additional information that should be included in the documentation. 10 (10%) – 12 (12%) The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation. 7 (7%) – 9 (9%) The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation. 4 (4%) – 6 (6%) The response vaguely and/or with some inaccuracy analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation. 0 (0%) – 3 (3%) The response inaccurately analyzes or is missing analysis of the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation. Is the assessment supported by the subjective and objective information? Why or why not? 14 (14%) – 16 (16%) The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation. 11 (11%) – 13 (13%) Soap Note Analysis Assignment Discussion Paper

The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation. 8 (8%) – 10 (10%) The response vaguely and/or inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation. 0 (0%) – 7 (7%) The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? 18 (18%) – 20 (20%) The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis. 15 (15%) – 17 (17%) The response accurately describes appropriate diagnostic tests for the case and explains clearly and accurately how the test results would be used to make a diagnosis. 12 (12%) – 14 (14%) The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis. 0 (0%) – 11 (11%) The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis. · Would you reject or accept the current diagnosis? Why or why not? · Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature. 23 (23%) – 25 (25%) The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning Soap Note Analysis Assignment Discussion Paper.

The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three different references from current evidence-based literature. 20 (20%) – 22 (22%) The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained accurately using three different references from current evidence-based literature. 17 (17%) – 19 (19%) The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two or three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three references from current evidence-based literature. 0 (0%) – 16 (16%) The response inaccurately or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies two or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using three or fewer references from current evidence-based literature. 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. 5 (5%) – 5 (5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 (4%) – 4 (4%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 (3%) – 3 (3%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time Soap Note Analysis Assignment Discussion Paper.

Purpose, introduction, and conclusion of the assignment are vague or off topic. 0 (0%) – 2 (2%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. 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. 4 (4%) – 4 (4%) Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 (3%) – 3 (3%) Contains several (3 or 4) grammar, spelling, and punctuation errors. 0 (0%) – 2 (2%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. 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. 5 (5%) – 5 (5%) Uses correct APA format with no errors. 4 (4%) – 4 (4%) Contains a few (1 or 2) APA format errors. 3 (3%) – 3 (3%) Contains several (3 or 4) APA format errors. 0 (0%) – 2 (2%) Contains many (≥ 5) APA format errors. Total Points: 100 Name: NURS_6512_Week_6_Assignment_1_Rubric Soap Note Analysis Assignment Discussion Paper