The Assignment
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.
The Assignment
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
3. Is the assessment supported by the subjective and objective information? Why or why not?
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5. 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.
Welcome to Week 6. This week, students will complete an analysis of the SOAP note provided. I advise you to write this up as a narrative so that they are able to correctly explain their analysis. REMEMBER THIS IS AN ANALYSIS FROM EACH PART OF THE SOAP POINTING TO WHAT’S MISSING AND WHY DO YOU NEED THAT SECTION WITH SPECIFICS JUSTIFYING AND EXPLAINING EVERYTHING INCLUDIDNG THE DIAGNOSIS
This week, the midterm examination is due by Day 7. Students can find an exam review guide for the midterm in the “Resources” section for this week. The exam will not be available until the date of availability and will end promptly on the end date and time. Please make sure you understand this. No outside resources including books, notes, websites, or any other type of resource are to be used to complete this exam. Students are expected to comply with Walden University’s Code of Conduct.
This exam will be on topics covered in weeks 1, 2, 3, 4, 5, and 6. This exam is timed with a limit of two hours for completion. The exam will not open until the day it is scheduled to open. If the students try to access the exam after the due date, it will be available and will show up late so your grade will reflect points deduction for lateness accordingly. IT or faculty are no longer allowed to reset exams.
In another note, I keep receiving emails about resetting your mistakes when posting. This is a clinical class, when you do not pay attention to the place to post or post a wrong paper it’s considered a patient mistake or a medical error. I would NOT reset another paper so do not bother emailing me if that’s the problem. I will grade what you post right or wrong, it is the student responsibility to post the right work same as it’s your responsibility to give the right medication.
This week a will be out of town in a conference until Friday so there are no office hours for the week and my email access will be limited. Everything needed it’s on this announcement and on the class website.
Assignment:
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
