LAB ASSIGNMENT: ASSESSING THE ABDOMEN A male went to the emergency room for seve

LAB ASSIGNMENT: ASSESSING THE ABDOMEN
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
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:
o    Review this week’s Learning Resources, and consider the insights they provide about the case study.
o    Consider what history would be necessary to collect from the patient in the case study.
o    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?
o    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.
In this Assessment 1 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. Just add in what you want to this case to make it unique to you. Do not use NA or normal.

ABDOMINAL ASSESSMENT

Subjective:

    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 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: ?

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.

With regard to the SOAP note case study provided, address the following:Analyze the subjective portion of the note. List additional information that should be included in the documentation — The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation. — The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.
This criterion is linked to a Learning OutcomeIs the assessment supported by the subjective and objective information? Why or why not? — The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.

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