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Assessment 1: Assessing the Abdomen Soap Note

Assessment 1: Assessing the Abdomen Soap Note Assessment 1: Assessing the Abdomen Soap NoteA 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. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen.Assessment 1: Assessing the Abdomen Soap NoteIn this assignment, you will analyze a SOAP 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.ORDER A PLAGIARISM-FREE PAPER HEREAbdominal AssessmentSUBJECTIVE: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. 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 agoMedications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhsAllergies: NKDAFH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERDSocial: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)OBJECTIVE:Assessment 1: Assessing the Abdomen Soap NoteVS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbsHeart: RRR, no murmursLungs: CTA, chest wall symmetricalSkin: Intact without lesions, no urticariaAbd: soft, hyperctive bowel sounds, pos pain in the LLQDiagnostics: NoneASSESSMENT:Left lower quadrant painGastroenteritisPLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.To prepare:Assessment 1: Assessing the Abdomen Soap NoteWith 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?Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.To complete:Assessment 1: Assessing the Abdomen Soap NoteAnalyze 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 3 different references from current evidence based literature.Assessment 1: Assessing the Abdomen Soap NoteReminder: Please make sure the paper includes introduction (including a purpose statement) and peer reviewed references. Lastly please follow uploaded rubric  SOAP Note Case Study AnalysisObtaining comprehensive subjective and objective data in a patient with abdominal pains is crucial. Additional information to be included in the subjective data would be health maintenance and immunization. This is through finding out whether the patient receives any regular vaccines,gynecological exams like Pap smear. Also, heroccupation, exercise and diet habits should be elicited when taking social history. Moreover, review of system (ROS) is vital. One should find out any complaints in terms headaches, fatigue, itching, ear pains, eye pains, chest pains, loss of smell or taste senses, nausea,sore throat, gastric abnormalities, and urinary problems (Domino, 2010). The obstetric and gynecological history is crucial for a female patient. This includesmenstruation and contraception history. Menstruation history would help rule out ectopic pregnancy.Assessment 1: Assessing the Abdomen Soap NoteDocumentation of objective data would include a comprehensive head to toe examination and the positive and negative findings. HEENT exam should be done to check for pallor and other abnormalities. Palpation to exclude abdominal wall or intraabdominal masses should be done. Percussions to rule out other abnormalities like ascites,the extent of abdominal masses, and liver enlargement.A digital rectal examination should also be recommended. Obesity is a risk factor for diverticulitis,therefore, BMI calculations should be included. A rectal examination would be done to check for any bleeding. Lastly, a pelvic exam is done to check for any palpable mass.Assessment 1: Assessing the Abdomen Soap NoteThe assessment is supported by the by the subjective and objective data. This is because diverticulitis presents with cramping abdominal pains, bowel habit changes,and nausea. The patients presented with similar signs and symptoms of severe abdominal cramping,diarrhea,nausea,localized pain in the lower left quadrant.Various diagnostic tests can be done to confirm the diagnosis. A complete blood count would be done to check for elevated white blood cell count and a drop in hematocritcommonin diverticulitis. Liver tests to exclude other abdominal pain causes.Abdominal x-ray and ultrasound would be done to confirm the diverticulitis. Also, a computed tomography scan with oral and intravenous contrast mediahelps in diagnosing the cause of left lower quadrant (LLQ) pain that may be similar to diverticulitis. Magnetic resonance imaging would indicate the presence of abscess or fistula which is associated with diverticulitis. A colonoscopy to check on the extent of diverticulitis or rule out other malignancies would be recommended (Lahat, etal., 2013).Assessment 1: Assessing the Abdomen Soap NoteAccording to the subjective and objective data,the diagnosis of diverticulitis is acceptable. This is because it presents with severe abdominal cramping, diarrhea, nausea, and localized pain in the lower left quadrant. This was noted in the patient.There are other three possible differential diagnoses for diverticulitis.The first would be acute appendicitis with colon involvement. It is a condition where the appendix is infected or obstructed. It presents with nausea and vomiting, and abdominal pains (Nshuti, Kruger &Luvhengo,2014).The patient complains of generalized abdominal pains with a gradual increase in intensity usually associated with appendicitis.The second differential diagnosis is colitis, an inflammatory bowel disease that presents with fever, cramping pains, nausea,and vomiting, lowersided abdominal pains and weight loss in very severe cases (Ananthakrishnan, et al., 2016).The third is colorectal cancer which presents with abdominal pains, bowel habit changes,diarrhea,rectal bleeding on examination, and bloodstained stool (Granados-Romero, etal., 2017).Assessment 1: Assessing the Abdomen Soap NoteIn conclusion, making a diagnosis of patient s presenting with abdominal pain can be a challenge. Obtainingthehistory correctly and interpreting theobjective datacan assist the physician to make the right diagnosis and save the life of the patient.Assessment 1: Assessing the Abdomen Soap Note  ReferencesAnanthakrishnan, A., Shi, H., Tang, W., Law, C., Sung, J., Chan, F., & Ng, S. (2016). Systematic review and meta-analysis: phenotype and clinical outcomes of older-onset inflammatory bowel disease. Journal of Crohn’s and Colitis, 10(10), 1224-1236.Domino,F.J. (Eds.). (2010).The5-minute clinical consult. Philadelphia: Lippincott Williams & WilkinsGranados-Romero JJ,Valderrama-Treviño AI, Contreras-Flores EH, Barrera-MeraB,Enríquez MH, Uriarte-Ruíz K, et al. (2017 ).Colorectal cancer: a review. Int J Res MedSci; 5:4667-76.Colorectal cancer: a review (PDF Download Available). Retrived from: A, Avidan B, Sakhnini E, Katz L, Fidder HH, Meir SB.(2013). Acute diverticulitis: a decade of prospective follow-up. J ClinGastroenterol.47(5):415-9. [Medline].Nshuti R, Kruger D, Luvhengo TE.(2014). Clinical presentation of acute appendicitis in adults at the Chris Hani Baragwanath academic hospital.Int J Emerg Med,; 7: 12. Assessment 1: Assessing the Abdomen Soap Note

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