Make a SOAP Note Not a narrative essay: Assessing the Abdomen

Note: Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template in the attachments below for guidance.

CASE: A 20-year-old female complains of nausea and has vomited three times over the past 48 hours. The patient also experienced a low-grade fever this morning. She states that she recently ate shellfish at a new restaurant with two friends who are suffering from similar symptoms.

To prepare:

With regard to the case study:

• 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 you were assigned.

• 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.

Address all these in the SOAP Note not an Narrative Essay (Follow the SOAP Note Template on the attachment):

1. A description of the health history you would need to collect from the patient in the case study to which you were assigned.

2. Explain which physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

3. A description of the health history you would need to collect from the patient in the case study 2.

4. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.

5. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

REMINDER:Please make a SOAP NOTE for this case. Make your own patient’s data, applicable health history, review of systems, P.E., labs, differential diagnosis, final diagnosis etc. Incorporate the data from the case in the SOAP note that you will do… This is not a narrative essay ok…. I need SOAP note (Nurse Practitioner/RN/MD makes SOAP note)… Be guided with the SOAP Note in the templates/exemplar… Don’t copy paste. Formulate your own… Don’t forget to cite the Five different possible conditions (Differential diagnosis) and have Reference lists too.

Resources:

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

o Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)

This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment.

o Chapter 17, “Abdomen” (pp. 370-415)

In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment on the abdomen.

• Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

o Chapter 3, “Abdominal Pain” (pp. 11-32)

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.

o Chapter 10, “Constipation” (pp. 110-117)

The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests.

o Chapter 12, “Diarrhea” (pp. 133-147)

In this chapter, the authors focus on diagnosing the cause of diarrhea. 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.

o Chapter 29, “Rectal Pain, Itching, and Bleeding” (pp. 344-356)

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.

• Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.

o Chapter 7, “Admitting a Patient to the Hospital” (pp. 143-188)

Note: Download this Adult Examination Checklist and Abdomen Physical Exam Summary to use during your practice abdominal examination.

• Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for abdominal assessment. In Mosby’s guide to physical examination(7th ed.). St. Louis, MO: Elsevier Mosby.

This Adult Examination Checklist: Guide for Abdominal Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). Fromhttps://evolve.elsevier.com/

• Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Abdomen. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

This Abdomen Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

• Craig, M., & Infante, S. (2011). Abdominal mysteries: Pain, peritonitis, pancreatitis. Nephrology Nursing Journal, 38(2), 173-186.

Retrieved from the Walden Library databases.

This article explains various types of abdominal pain. The authors detail the etiologies, symptoms, and treatment for the abdominal pain described.

• Mills, A. M., & Chen, E. H. (2011). Abdominal pain in special populations. Emergency Medicine Reports, 32(7), 81-91.

Retrieved from the Walden Library databases.

The authors of this article explore the characteristics and diagnoses associated with abdominal pain in patients with special conditions. The article also provides recommendations for emergency department staff when encountering abdominal pain.

• University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved fromhttp://www.med-ed.virginia.edu/courses/rad/index.html

This website provides an introduction to radiology and imaging. For this week, focus on gastrointestinal radiology.

Media

Online media for Seidel’s Guide to Physical Examination

It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 7, and 17 that relate to the assessment of the abdomen and gastrointestinal system. Refer to Week 4 for access instructions onhttps://evolve.elsevier.com/.

Optional Resources

• LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.

o Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” (pp. 445-527)

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.

o Chapter 10, “The Urinary System” (pp. 528-540)

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.