Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note

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Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note

Proper evaluation of a patient before making the diagnosis is an art that all clinicians must strive to perfect. This is because the consequences of an incorrect diagnosis on the patient and patient outcomes are immense. A correct diagnosis enables the immediate commencement of the appropriate therapy. The patient then recovers faster and hospitalization days are substantially reduced. With a reduced duration of hospitalization comes a lower cost of hospitalization for the patient. This is why all clinicians (APRNs, physicians, and physician assistants) must know what to do, what to ask, where to examine, and which diagnostic tests to order (Ball et al., 2019; Bickley, 2017).  Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note.This paper is the analysis of the SOAP Note of a 47 year-old White male with left lower quadrant pain, diarrhea, and nausea. The analysis focuses on the missing information from the subjective, objective, and assessment portions.

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Analysis of the Subjective Part

From the analysis of the subjective part of the SOAP note, the following information is missing from the documentation and should therefore be included:

  1. Some parts of the mnemonic POLDCARTS in the HPI: There is information missing about whether the patient has a previous history of the symptoms (P). Also needed is information about the duration of the abdominal pain or how long it lasts (D). The other missing information is about the characteristics of the pain or whether it is dull, sharp, et cetera (C). Aggravating factors that make the abdominal pain worse are also missing (A), as are relieving factors (R) that make the abdominal pain better. Lastly is the timing (T) of the pain or when it is noticed by the patient.
  2. Immunization history: There needs to be information about the immunization history of patient J.R. this should cover childhood immunization as well as the last influenza and Tdp booster injections.
  • Review of Systems (ROS): This is a review of all the systems from a subjective (or patient’s) point of view. This information to be included is as follows:

General: He denies any fatigue, fever, weakness, or recent weight loss.

HEENT: He denies having headaches. He also denies having photophobia, diplopia, or tearing. The last visit to an ophthalmologist was three months ago. He also denies tinnitus, otorrhea, or hearing loss. He has no rhinorrhea, sneezing, or epistaxis. He also says he does not have a sore throat or dysphagia. He last visited his ENT specialist eight months ago.  Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note.

Gastrointestinal: He reports significant abdominal disturbance. He has diarrhea, abdominal pain that is generalized, and nausea. There has been a change in his bowel habits for three days now. His latest bowel movement had been at the hospital a few minutes before coming in for consultation.

Cardiovascular: He denies palpitations, tightness of the chest, pain in the chest, or tachycardia.

Integumentary (skin): He denies rashes, urticaria, itchiness, or any skin discoloration.

Respiratory: 47 year-old patient J.R. also denies coughing, experiencing difficulties in breathing, or lack of exercise tolerance.

Genitourinary: He denies painful micturition, cloudy urine, oliguria, polyuria, or anuria. He is heterosexual, is married, and has 3 children.

Musculoskeletal: He denies arthralgia, myalgia, or any limitation in the range of movement in his joints. He also denies having any back pains.

Endocrinologic: He denies ever having hormonal therapy. He also denies excessive diaphoresis, polydipsia, and polyphagia. He does not have heath intolerance too.

Neurological: He denies urinary or bowel incontinence. He also denies syncope, loss of consciousness, or peripheral paraesthesia.

Hematologic: He does not have a history of blood disorders or problems with blood clotting. He also denies feeling dizzy or fainting. He does not have unexplained bruising on his body.

Psychiatric: Patient J.R. denies suffering from any sort of mental illness such as depression or anxiety.

Lymphatics: He denies lymphadenopathy or a history of splenectomy. Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note.

Allergic/ Immunologic: He denies allergic rhinitis, eczema, asthma, or hives. He does not suffer any allergies to foods, medications, or environmental triggers such as smoke and dust.

Analysis of the Objective Part

In analyzing the objective portion of patient J.R.’s SOAP note, some information was also found to be missing in the documentation. This additional information that should be included in the documentation is:

  1. General/ constitutional assessment: He is alert and oriented in person, space, place, and event (A&O x 3). His speech is spontaneous and goal-directed. There is no ataxia or gait disturbance and the patient is dressed appropriately for the weather and time of the day.
  2. HEENT: Head is normocephalic and atraumatic. Both pupils equal, round, and reacting to light and accommodation (PERRLA). Extraocular movements intact (EOMI). No strabismus. Ears no otorrhea, tympanic membranes intact bilaterally with no fluid level. Nose no deviated septum, no inflamed turbinates, and no rhinorrhea. The throat is clear with no exudate.

The Assessment

The assessment of left lower quadrant (LLQ) pain and a diagnosis of gastroenteritis (GE) are indeed feasible and possible given the subjective and objective information. So yes, the assessment is supported by the subjective and objective information. The reason for this conclusion is that the patient in his chief complaint clearly admits that they have diarrhea and their abdomen hurts. This is consistent with gastroenteritis which normally presents with diarrhea, nausea, low-grade fever, and abdominal cramps (Hammer & McPhee, 2018). Patient J.R. has a low-grade fever of 99.8°F. The diagnosis of GE is therefore congruent with the subjective and objective information presented.

Diagnostics

The diagnostic tests that would be appropriate for this case would be:

  1. Computerized tomography angiography (CTA) of the abdomen
  2. A complete blood count (CBC)
  • Urinalysis
  1. Stool for microscopy, culture, and sensitivity
  2. Metabolic panel (Hammer & McPhee, 2018).

The CTA would reveal any pathophysiological process affecting the abdominal organs (e.g. pancreatic cancer or diverticulitis). A CBC would show if there is an infection while a urinalysis would any UTI that may be the cause of the LLQ pain. The stool sample for M/C/S would help with confirmation of GE and the treatment. Lastly, performing a metabolic panel is advisable especially because thus patient is both hypertensive and diabetic. The results would serve as baseline values for further management.

The Diagnosis

I would accept the current diagnosis of GE. The reason for this is that the subjective information (diarrhea, nausea, abdominal pain/ cramps) and the objective information (hyperactive bowel sounds and low-grade fever) support the diagnosis. Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note. Three possible conditions that may be considered as differential diagnosis for this patient are:

  1. Acute sigmoid diverticulitis (Huether & McCance, 2017; Hammond et al., 2010): This is the most likely differential as it is a common cause of LLQ pain and is usually confirmed by CTA of the abdomen, according to Hammond et al. (2010).
  2. Prostatitis (Huether & McCance, 2017; Hammond et al., 2010): it is a likely consideration in middle-aged male patients with LLQ pain.
  3. Nephrolithiasis (Jameson et al., 2018): Ureteric nephrolithiasis is a clinical possibility.

Conclusion

The SOAP note for 47 year-old patient J.R. had a number of information pieces that were missing in the documentation. This paper has been able to demonstrate and document those missing pieces of information from the subjective, objective, and assessment portions of the note. This missing information is very important in making the final decision about the patient’s diagnosis and differential diagnoses. This, too, has been demonstrated in this paper, including by providing three possible differential diagnoses to the one made at the end of the SOAP note.

 

References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12th ed. Wolters Kluwer.

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.

Hammond, N.A., Nikolaidis, P., & Miller, F.H. (2010). Left lower-quadrant pain: Guidelines from the American College of Radiology appropriateness criteria. American Family Physician, 82(7), 766-770. Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note. https://www.aafp.org/afp/2010/1001/p766.html#:~:text=The%20differential%20diagnosis%20of%20left,guided%20by%20the%20clinical%20presentation

Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6th ed. Elsevier, Inc.

Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., & Loscalzo, J. (Eds) (2018). Harrison’s principles of internal medicine, 20th ed. McGraw-Hill Education.  Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note.

Assignment 1: Lab Assignment: Assessing the Abdomen

A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CT scan. The CT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.
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 conditions.
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? Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note.
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.

STRICTLY FOLLOW BELOW FROM THE PROFESSOR
1. In this Assessment 1 Assignment, you will analyze an Episodic Note case study that describes abnormal findings in patients seen in a clinical setting. This is in a scholarly paper format and not SOAP format this week. 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. Follow the rubric…..Be sure to use APA format…..and upload by Day 7.
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: None
Assessment:•Left lower quadrant pain •Gastroenteritis
PLAN: This section is not required for the assignment.

Rubric

• Grid View
• List View
Excellent Good Fair Poor
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. 10 (10%) – 12 (12%)
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. 7 (7%) – 9 (9%)
The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation. 4 (4%) – 6 (6%) Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note.
The response vaguely and/or with some inaccuracy analyzes the subjective portion of the SOAP note and vaguely and/or with some inaccuracy lists additional information to be included in the documentation. 0 (0%) – 3 (3%)
The response inaccurately analyzes or is missing analysis of the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation. 10 (10%) – 12 (12%)
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. 7 (7%) – 9 (9%)
The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation. 4 (4%) – 6 (6%)
The response vaguely and/or with some inaccuracy analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation. 0 (0%) – 3 (3%)
The response inaccurately analyzes or is missing analysis of the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not? 14 (14%) – 16 (16%)
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. 11 (11%) – 13 (13%)
The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation. 8 (8%) – 10 (10%)
The response vaguely and/or inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation. 0 (0%) – 7 (7%)
The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? 18 (18%) – 20 (20%) Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note.
The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis. 15 (15%) – 17 (17%)
The response accurately describes appropriate diagnostic tests for the case and explains clearly and accurately how the test results would be used to make a diagnosis. 12 (12%) – 14 (14%)
The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis. 0 (0%) – 11 (11%)
The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.
· Would you reject or accept the current diagnosis? Why or why not?
· Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature. 23 (23%) – 25 (25%)
The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three different references from current evidence-based literature. 20 (20%) – 22 (22%)
The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained accurately using three different references from current evidence-based literature. 17 (17%) – 19 (19%) Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note.
The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two or three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three references from current evidence-based literature. 0 (0%) – 16 (16%)

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The response inaccurately or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies two or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using three or fewer references from current evidence-based literature.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation 5 (5%) – 5 (5%) Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note.
Uses correct grammar, spelling, and punctuation with no errors. 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors. 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. 5 (5%) – 5 (5%)
Uses correct APA format with no errors. 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors. 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors. 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors. Lab Assignment: Assessing the Abdomen by Analyzing a SOAP Note.