Assignent Solutionnurs

Here is the SOAP for analysis for week 6. You need to analyze each
section and determine what information is missing or incomplete. The
following questions must be addressed:
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.
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: Hypertension, 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:
Abdominal Aortic Aneurysm
(AAA)
Perforated Ulcer
Pancreatitis
PLAN: This section is not required for the
assignments in this course (NURS 6512) but will be required for future courses.Here is the SOAP for analysis for week 6. You need to analyze each
section and determine what information is missing or incomplete. The
following questions must be addressed:
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.
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: Hypertension, 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:
Abdominal Aortic Aneurysm
(AAA)
Perforated Ulcer
Pancreatitis
PLAN: This section is not required for the
assignments in this course (NURS 6512) but will be required for future courses.