Advanced Health Assessment 19964381

Assignment 1: Lab Assignment: Assessing the Abdomen

 Please note this assignment is due week 6.  Please refer to your resource list as well as your grading rubrics and study guide for week 6. 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 conditions. Please use your Resource list and grading rubric as a guide. Please reach out to me if you have any questions regarding this assignment

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: None

Assessment: Left lower quadrant pain Gastroenteritis

PLAN:  This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

 

To Prepare

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.

The Assignment 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.
Rubric Detail  

Select Grid View or List View to change the rubric’s layout.Name: NURS_6512_Week_6_Assignment_1_Rubric

[removed]Grid ViewList View ExcellentGoodFairPoorWith 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. 10 (10%)  – 12 (12%) 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. 7 (7%)  – 9 (9%) The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation. 4 (4%)  – 6 (6%) 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. 0 (0%)  – 3 (3%) 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. 10 (10%)  – 12 (12%) 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. 7 (7%)  – 9 (9%) The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation. 4 (4%)  – 6 (6%) 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. 0 (0%)  – 3 (3%) 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? 14 (14%)  – 16 (16%) 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. 11 (11%)  – 13 (13%) The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation. 8 (8%)  – 10 (10%) 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. 0 (0%)  – 7 (7%) The response inaccurately identifies 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? 18 (18%)  – 20 (20%) 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. 15 (15%)  – 17 (17%) 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. 12 (12%)  – 14 (14%) 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. 0 (0%)  – 11 (11%) 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 references from current evidence-based literature. 23 (23%)  – 25 (25%) 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. 20 (20%)  – 22 (22%) 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. 17 (17%)  – 19 (19%) 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. 0 (0%)  – 16 (16%) 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.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 purpose statement and introduction are provided that delineate all required criteria. 5 (5%)  – 5 (5%) 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 (4%)  – 4 (4%) 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 (3%)  – 3 (3%) 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. 0 (0%)  – 2 (2%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation 5 (5%)  – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors. 4 (4%)  – 4 (4%) Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 (3%)  – 3 (3%) Contains several (3 or 4) grammar, spelling, and punctuation errors. 0 (0%)  – 2 (2%) 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 (5%)  – 5 (5%) Uses correct APA format with no errors. 4 (4%)  – 4 (4%) Contains a few (1 or 2) APA format errors. 3 (3%)  – 3 (3%) Contains several (3 or 4) APA format errors. 0 (0%)  – 2 (2%) Contains many (≥ 5) APA format errors.Total Points: 100 Name: NURS_6512_Week_6_Assignment_1_Rubric

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