{"id":11456,"date":"2020-11-24T09:02:04","date_gmt":"2020-11-24T09:02:04","guid":{"rendered":"http:\/\/onlineclassesguru.com\/index.php\/2020\/11\/24\/a-soap-note-case-study\/"},"modified":"2020-11-24T09:02:04","modified_gmt":"2020-11-24T09:02:04","slug":"a-soap-note-case-study","status":"publish","type":"post","link":"https:\/\/onlineclassesguru.com\/index.php\/2020\/11\/24\/a-soap-note-case-study\/","title":{"rendered":"A SOAP Note Case Study"},"content":{"rendered":"<style type=\"text\/css\"><\/style><div class=\"entry-content\">\n<div id=\"pryc-wp-acctp-top\"><\/div>\n<div id=\"pryc-wp-acctp-original-content\"><strong>In this assignment, you will analyze a SOAP 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.<\/strong><strong>Abdominal Assessment<\/strong><\/p>\n<p><strong>SUBJECTIVE:<\/strong><\/p>\n<p>\u00b7\u00a0<strong>CC: \u201cMy stomach hurts, I have diarrhea and nothing seems to help.\u201d<\/strong><\/p>\n<p>\u00b7\u00a0<strong>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.<\/strong><\/p>\n<p>\u00b7\u00a0<strong>PMH: HTN, Diabetes, hx of GI bleed 4 years ago<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Allergies: NKDA<\/strong><\/p>\n<p>\u00b7\u00a0<strong>FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)<\/strong><\/p>\n<p><strong>OBJECTIVE:<\/strong><\/p>\n<p>\u00b7\u00a0<strong>VS: Temp 99.8; BP 160\/86; RR 16; P 92; HT 5\u201910\u201d; WT 248lbs<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Heart: RRR, no murmurs<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Lungs: CTA, chest wall symmetrical<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Skin: Intact without lesions, no urticaria<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Abd: soft, hyperctive bowel sounds, pos pain in the LLQ<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Diagnostics: None<\/strong><\/p>\n<p><strong>ASSESSMENT:<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Left lower quadrant pain<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Gastroenteritis<\/strong><\/p>\n<p>\u00b7\u00a0<strong>PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.<\/strong><\/p>\n<p><strong>To prepare:<\/strong><\/p>\n<p><strong>With regard to the SOAP note case study provided:<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Review this week\u2019s Learning Resources, and consider the insights they provide about the case study.<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Consider what history would be necessary to collect from the patient in the case study.<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\u2019s condition. How would the results be used to make a diagnosis?<\/strong><\/p>\n<p>\u00b7\u00a0<strong>Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.<\/strong><\/p>\n<p><strong>To complete:<\/strong><\/p>\n<p><strong>1.<\/strong>\u00a0<strong>Analyze the subjective portion of the note. List additional information that should be included in the documentation.<\/strong><\/p>\n<p><strong>2.<\/strong>\u00a0<strong>Analyze the objective portion of the note. List additional information that should be included in the documentation.<\/strong><\/p>\n<p><strong>3.<\/strong>\u00a0<strong>Is the assessment supported by the subjective and objective information? Why or Why not?<\/strong><\/p>\n<p><strong>4.<\/strong>\u00a0<strong>What diagnostic tests would be appropriate for this case and how would the results be used to make a diagnosis?<\/strong><\/p>\n<p><strong>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<\/strong><\/p>\n<\/div>\n<\/div>\n<p><center><a href=\"http:\/\/onlineclassesguru.com\/orders\/ordernow\"><img decoding=\"async\" src=\"https:\/\/encrypted-tbn0.gstatic.com\/images?q=tbn:ANd9GcTyj99p60XCLyLk1htB7-1neRt8-2QdnenNlQ&usqp=CAU\"target=\"_http:\/\/onlineclassesguru.com\/orders\/ordernow\"\/><\/center><p>","protected":false},"excerpt":{"rendered":"<p>In this assignment, you will analyze a SOAP 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&#8230;<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[],"tags":[],"class_list":["post-11456","post","type-post","status-publish","format-standard","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v17.0 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>A SOAP Note Case Study - onlineclassesguru<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"http:\/\/onlineclassesguru.com\/index.php\/2020\/11\/24\/a-soap-note-case-study\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"A SOAP Note Case Study - onlineclassesguru\" \/>\n<meta property=\"og:description\" content=\"In this assignment, you will analyze a SOAP note case study that describes abnormal findings in patients seen in a clinical setting. 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