{"id":19706,"date":"2021-12-02T03:35:45","date_gmt":"2021-12-02T03:35:45","guid":{"rendered":"https:\/\/assignmenttutors.net\/blog\/a-soap-note-case-study-nurs-6512n-walden-university\/"},"modified":"2021-12-02T03:35:45","modified_gmt":"2021-12-02T03:35:45","slug":"a-soap-note-case-study-nurs-6512n-walden-university","status":"publish","type":"post","link":"https:\/\/assignmenttutors.net\/blog\/a-soap-note-case-study-nurs-6512n-walden-university\/","title":{"rendered":"A soap note case study | NURS – 6512N | Walden University"},"content":{"rendered":"
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\u00a0\u00a0<\/p>\n

In 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.<\/strong><\/p>\n

Abdominal Assessment<\/strong><\/p>\n

SUBJECTIVE:<\/strong><\/p>\n

\u00b7 CC: \u201cMy stomach hurts, I have diarrhea and nothing seems to help.\u201d<\/strong><\/p>\n

\u00b7 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.<\/strong><\/p>\n

\u00b7 PMH: HTN, Diabetes, hx of GI bleed 4 years ago<\/strong><\/p>\n

\u00b7 Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs<\/strong><\/p>\n

\u00b7 Allergies: NKDA<\/strong><\/p>\n

\u00b7 FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD<\/strong><\/p>\n

\u00b7 Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)<\/strong><\/p>\n

OBJECTIVE:<\/strong><\/p>\n

\u00b7 VS: Temp 99.8; BP 160\/86; RR 16; P 92; HT 5\u201910\u201d; WT 248lbs<\/strong><\/p>\n

\u00b7 Heart: RRR, no murmurs<\/strong><\/p>\n

\u00b7 Lungs: CTA, chest wall symmetrical<\/strong><\/p>\n

\u00b7 Skin: Intact without lesions, no urticaria<\/strong><\/p>\n

\u00b7 Abd: soft, hyperctive bowel sounds, pos pain in the LLQ<\/strong><\/p>\n

\u00b7 Diagnostics: None<\/strong><\/p>\n

ASSESSMENT:<\/strong><\/p>\n

\u00b7 Left lower quadrant pain<\/strong><\/p>\n

\u00b7 Gastroenteritis<\/strong><\/p>\n

\u00b7 PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.<\/strong><\/p>\n

To prepare:<\/strong><\/p>\n

With regard to the SOAP note case study provided:<\/strong><\/p>\n

\u00b7 Review this week\u2019s Learning Resources, and consider the insights they provide about the case study.<\/strong><\/p>\n

\u00b7 Consider what history would be necessary to collect from the patient in the case study.<\/strong><\/p>\n

\u00b7 Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\u2019s condition. How would the results be used to make a diagnosis?<\/strong><\/p>\n

\u00b7 Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.<\/strong><\/p>\n

To complete:<\/strong><\/p>\n

1.<\/strong> Analyze the subjective portion of the note. List additional information that should be included in the documentation.<\/strong><\/p>\n

2.<\/strong> Analyze the objective portion of the note. List additional information that should be included in the documentation.<\/strong><\/p>\n

3.<\/strong> Is the assessment supported by the subjective and objective information? Why or Why not?<\/strong><\/p>\n

4.<\/strong> What diagnostic tests would be appropriate for this case and how would the results be used to make a diagnosis?<\/strong><\/p>\n

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<\/strong>\u00a0<\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

\u00a0\u00a0 In 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 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[31],"tags":[],"class_list":["post-19706","post","type-post","status-publish","format-standard","hentry","category-homework-help"],"_links":{"self":[{"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/posts\/19706","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/comments?post=19706"}],"version-history":[{"count":0,"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/posts\/19706\/revisions"}],"wp:attachment":[{"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/media?parent=19706"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/categories?post=19706"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/tags?post=19706"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}