Assessing the Abdomen

In this 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 identify three possible conditions that may be considered as a differential diagnosis for this patient.

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:

PLAN: This section is not required.

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.

Criteria

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.

12 pts

Analyze the objective portion of the note. List additional information that should be included in the documentation.

12 pts

Is the assessment supported by the subjective and objective information? Why or why not?

16 pts

What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

20 pts

Would you reject or 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.

2

5 pts

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 pts

Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

5 pts

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 pts

Total Points: 100

Ratings	Pts
12 to >9.0 pts Excellent 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. 9 to >6.0 pts Good The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation. 6 to >3.0 pts Fair 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. 3 to >0 pts Poor 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.
12 to >9.0 pts Excellent 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. 9 to >6.0 pts Good The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation. 6 to >3.0 pts Fair 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. 3 to >0 pts Poor 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.
16 to >13.0 pts Excellent 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. 13 to >10.0 pts Good The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation. 10 to >7.0 pts Fair 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. 7 to >0 pts Poor The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.
20 to >17.0 pts Excellent 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. 17 to >14.0 pts Good 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. 14 to >11.0 pts Fair 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. 11 to >0 pts Poor 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.
25 to >22.0 pts Excellent 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. 22 to >19.0 pts Good 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. 19 to >16.0 pts Fair 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. 16 to >0 pts Poor 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.
5 to >4.0 pts Excellent 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 to >3.0 pts Good 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 to >2.0 pts Fair 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. 2 to >0 pts Poor Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
5 to >4.0 pts Excellent Uses correct grammar, spelling, and punctuation with no errors. 4 to >3.0 pts Good Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 to >2.0 pts Fair Contains several (3 or 4) grammar, spelling, and punctuation errors. 2 to >0 pts Poor Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 to >4.0 pts Excellent Uses correct APA format with no errors. 4 to >3.0 pts Good Contains a few (1 or 2) APA format errors. 3 to >2.0 pts Fair Contains several (3 or 4) APA format errors. 2 to >0 pts Poor Contains many (≥ 5) APA format errors.