- 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)
- 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, hyperctive bowel sounds, pos pain in the LLQ
- Diagnostics: None
- Left lower quadrant pain
- PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
With regard to the SOAP 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.
- 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 3 different references from current evidence based literature.
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