please read the teacher’s instructions carefully
Assignment 1: Lab Assignment
You will analyze an Episodic note case study (listed below) that describes abnormal findings in patients seen in a clinical setting. WRITE THIS UP AS A NARRATIVE so that you are able to correctly explain the analysis. 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.
Please DO NOT write this up in a soap note format.
You are NOT completing a soap note but analyzing all the information provided and discussing in your narrative what information is missing. You need to take all of the information presented into consideration to determine what is missing. Then you what consider and what is normally documented in the soap note for the various parts of the note. Please use your textbook guide to clinical documentation to help with this assignment. It will be a great source to use for this assignment as well as the required resources for this week.
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.
ABDOMINAL ASSESSMENT
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
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
The Assignment + introduction+ conclusion + references pages
(wrote there narrative under each question).
Analyze 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 three different references from current evidence-based literature.
Not explain altogether. Write each question with its answer individually.
using formal APA writing convention, using the 7th Edition
References at least 5 and not more than 5 years ago
Plagiarism free work…. Thank you
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 6, “Vital Signs and Pain Assessment”
This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment.
Chapter 18, “Abdomen”
In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment of the abdomen.
