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Episodic Focused SOAP Note

Episodic Focused SOAP Note

Episodic/Focused SOAP Note Assignment

1. For this week’s assignment you will analyze a SOAP note and complete your assignment based on the documentation provided below.  The assignment this week should be completed in the format of a NARRATIVE PAPER to better explain your analysis.

Below is the documentation you will use for your first assignment: 

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 

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ABDOMINAL ASSESSMENT

·       Subjective:

o   CC: “My stomach has been hurting for the past two days.”

o   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. 

o   PMH: HTN

o   Medications: Metoprolol 50mg

o   Allergies: NKDA

o   FH: HTN, Gerd, Hyperlipidemia

o   Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female 

·      Objective:

o   VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lb

o   Heart: RRR, no murmurs

o   Lungs: CTA, chest wall symmetrical

o   Skin: Intact without lesions, no urticaria

o   Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound.

·      Diagnostics: US and CTA

·      Assessment: 

o   Abdominal Aortic Aneurysm (AAA)

o   Perforated Ulcer

o   Pancreatitis

·      Evaluate abnormal abdomen and gastrointestinal findings

·      Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the abdomen and gastrointestinal system

·      Analyze chest X-Ray and abdominal X-Ray imaging

·      Identify concepts, theories, and principles related to advanced health assessment

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.

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