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.
In this Assessment 1 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. Just add in what you want to this case to make it unique to you. Do not use NA or normal.
ABDOMINAL ASSESSMENT
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: ?
Assessment:
Left lower quadrant pain
Gastroenteritis
,
10/3/23, 3:19 PM Week 6: Assignment 1
https://waldenu.instructure.com/courses/85632/assignments/884985?module_item_id=2747327 1/7
Due Sunday by 10:59pm Points 100 Submitting a text entry box or a file upload Attempts 0 Allowed Attempts 2
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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
LAB ASSIGNMENT: ASSESSING THE ABDOMEN
RESOURCES
10/3/23, 3:19 PM Week 6: Assignment 1
https://waldenu.instructure.com/courses/85632/assignments/884985?module_item_id=2747327 2/7
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.
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.
Submit your Lab Assignment.
Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.
WEEKLY RESOURCES (https://waldenu.instructure.com/courses/85632/modules/items/2747330)
TO PREPARE
THE ASSIGNMENT
BY DAY 7 OF WEEK 6
10/3/23, 3:19 PM Week 6: Assignment 1
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NURS_6512_Week_6_Assignment_1_Rubric
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SUBMISSION INFORMATION
10/3/23, 3:19 PM Week 6: Assignment 1
https://waldenu.instructure.com/courses/85632/assignments/884985?module_item_id=2747327 4/7
Criteria Ratings Pts
12 pts
12 pts
16 pts
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 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.
Analyze the objective portion of the note. List additional information that should be 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.
Is the assessment supported by the subjective and objective information? Why or why not?
16 to >13.0 pts Excellent
The response clearly and accurately
13 to >10.0 pts Good
The response accurately identifies whether
10 to >7.0 pts Fair
The response vaguely and/or inaccurately
7 to >0 pts Poor
The response inaccurately identifies
10/3/23, 3:19 PM Week 6: Assignment 1
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Criteria Ratings Pts
20 pts
25 pts
identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.
or not the assessment is supported by the subjective and/or objective information, with an explanation.
identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.
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?
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.
· 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
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
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
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
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
10/3/23, 3:19 PM Week 6: Assignment 1
https://waldenu.instructure.com/courses/85632/assignments/884985?module_item_id=2747327 6/7
Criteria Ratings Pts
5 pts
references from current evidence- based literature.
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.
identifies three conditions as a differential diagnosis, with reasoning that is explained accurately using three different references from current evidence- based literature.
as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three references from current evidence-based literature.
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
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.
10/3/23, 3:19 PM Week 6: Assignment 1
https://waldenu.instructure.com/courses/85632/assignments/884985?module_item_id=2747327 7/7
Total Points: 100
Criteria Ratings Pts
5 pts
5 pts
purpose statement and introduction are provided that delineate all required criteria.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
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.
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 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.
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