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5 pages/≈1375 words
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Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Essay
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English (U.S.)
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Topic:

The physical assessment for patient

Essay Instructions:

You will ANALYZE (DETAILED) a SOAP note case study Week_6 SOAP.pdf 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. Everything written needs to be detailed and explained. Please write this in Narrative and not SOAP note form.
Assignment 1: Lab Assignment: Assessing the Abdomen (this Case Study can be found in Wk 6 Module)
Your narrative should address:
Consider what additional 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 3 possible conditions that may be considered in a differential diagnosis for the patient.
Your SOAP note should have detailed:
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?

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. 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
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.
By Day 7 of Week 6

Essay Sample Content Preview:

Title
Your Name
Subject and Section
Professor’s Name
Date of Submission
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
The history taker must first complete the OPQRST in addition to the location—onset, precipitating factors, quality, relieving factors or radiation, severity or setting, and the timing, duration, and frequency (Bickley & Szilagyi, 2012).
The location is the most critical factor here, which is the left lower quadrant. This must be clarified since the patient stated that there is a generalized abdominal pain. It can be generalized when the patient cannot point out the actual source of pain. However, in this case, the patient was able to point it to the LLQ. The question must be followed by the onset. It has been stated that it started three days ago. From here, the history taker must ask the details that happened every day with a complete OPQRST. The onset must be accompanied by the specific questions such as, “What have you eaten during the previous day and the day?” and “What did you drink during the previous days and before the symptoms appear?” (Bickley & Szilagyi, 2012).
Additionally, the history taker must probe on the statement, “nothing seems to help.” He must ask for the aggravating or relieving factors such as a specific position that increases or decreases the pain. The history taker must also ask if it is affected by coughing, sneezing, or any Valsalva manoeuvre. Relieving factors may also include some first-aid methods such as putting on warm compress on the site of pain (Bickley & Szilagyi, 2012).
Furthermore, the history of GI bleed must be clarified on whether it is due to a malignancy, ulcer, and other diseases. Occasional alcoholic beverage drinking must be quantified by the approximate number of bottles per week and the type of drink to quantify the percentage of alcohol. This is important to allow the rule-in or rule-out of alcoholic liver disease and vitamin deficiencies (Cartwright & Knudson, 2008).
Changes in appetite, bowel movement, nausea, vomiting, and the use of OTC drugs must also be asked. It is also important to note the source of food and water, personal hygiene, and garbage collection and disposal methods (Cartwright & Knudson, 2008).
Lastly, a complete review of systems must be done (Bickley & Szilagyi, 2012).
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
The physical assessment for the abdomen must be focused but holistically done so as not to miss specific points. It is always essential to do a general survey and HEENT. The presence of malignancy can be suspected when there are positive signs of anaemia, such as pallor of the skin and mucous membranes. Jaundice and icteric sclerae must be noted for possible liver involvement. The presence of tattoos and piercings must also be noted to support or deny hepatitis infection. Lymph node enlargement, especially in the supraclavicular areas, must also be noted. The weight and BMI of the patient must also be noted since it is anorexia and cachexia are alarm signs for malignancy (Chen, Ca...
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