I have diarrhea, and nothing seems to help.
I have diarrhea, and nothing seems to help.
WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2
WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2
Week 6 Assignment 1: Lab Assessing the Abdomen
Walden University
NURS 6512 N
Silifat Jones-Ibrahim
Running head: WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2
Week 6 Assignment 1: Lab Assessing the Abdomen
Abdominal Assessment Case Study SOAP Note
Subjective:
•CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”
•HPI: JR, 47-year-old 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 ago
•Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
•Allergies: NKDA
•FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
•Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
•VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
•Heart: RRR, no murmurs
•Lungs: CTA, chest wall symmetrical
•Skin: Intact without lesions, no urticaria
•Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
•Diagnostics: None
Assessment:
•Left lower quadrant pain
•Gastroenteritis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Subjective Analysis
According to Ball et al, (2015) when treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses. Chief complaint needs to be “stomach hurts.” The HPI needs to include the timing and characteristics of abdominal pain, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. In the scenario, in the subjective part of the SOAP note, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. Also, additional information about any changes in appetite and bowel movements is also needed. The history of present illness should incorporate data like onset, duration, characteristics, exacerbating, and alleviating symptoms as it relates to abdominal pain. Location is one of the most critical questions to ask before the beginning exam (Ball,2015). Specifying which part of the abdomen with clarifying questions asked during the ROS which is missing altogether. Patient reports of not using his medications would go under medications the last time he took them, needs to identify the reason for each medication, and why stopped. Negative finding for colon cancer listed could have been a differential diagnosis consideration, then needs to be listed under the Assessment section. Lastly, the family history is required to go back to three generations with 2 out of 3 documented. It seems as if this practitioner got sidetracked with his ROS and forgot to note the rest of the PMHx or forgot to finish it. The lifestyle and exercise questions for diabetes and hypertension are good practice and required for proper medical documentation (Ball, Dains, Flynn, Solomon, & Stewart, 2019). CAGE screening ruling out alcoholism. How much is “occasional” drinking? How many, how often, and any repercussions?
The objective portion of the note and additional information that should be included in the documentation.
Objective Analysis
In the objective part of the SOAP note, the documentation still needs more information on the general appearance of the patient. This includes the rate at which the patient answers questions, if all questions are answered appropriately, if the hygiene of the patient is good, the mood, and the posture. The result of the inspection and percussion of the abdomen was not given, although the auscultation was done and was noted to be hyperactive and pain to the left lower quadrant.
Physical examination is out of order. Systems uniformly listed in a certain order to match head to toe assessments. The general assessment is completely missing from this section. Only positive findings and pertinent negative findings needed for the objective part of the SOAP note. The body systems that are listed need to be in a particular order when used HEENT before Neck, Neck before Chest, and so on. The SOAP for the case study would be VS General, Skin, Chest, Abdomen, and Genitourinary (Ball et al., 2019). These areas contain all the organs that may be the cause of abdominal pain. There were two positive findings in which this practitioner needed to use palpation and a stethoscope. The negative results for the rest of the examination need documentation for palpation and auscultation. Lastly, if JR has a history of GI bleed, where is the CBC, skin pallor, cap refill? If JR is a diabetic with diarrhea, where is his blood glucose and CMP? What is the character of LLQ palpation findings? Mass/no mass. Rebound tenderness? Sharp/dull does it travel? The practitioner might have suspected with the mention of the father having no colon cancer. Needed are CBC, CMP, HbA1c, Abd x-ray, stool guaiac, and stool WBC. Also, the colorectal exam performed along with prostate screening. Referral for EGD/colonoscopy, especially with his high risk for colon cancer and history of GI bleed (Sullivan*, 2019).
Is the Assessment Supported by S/O Information?
