Due on Sunday at 11PM NO PLAGERISM PLEASE READ CAREFULLY MUST BE A PAPER

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.–

Excellent 10 (10%) – 12 (12%)

Good 7 (7%) – 9 (9%)

Fair 4 (4%) – 6 (6%)

Poor 0 (0%) – 3 (3%)

Analyze the objective portion of the note. List additional information that should be included in the documentation.–

Excellent 10 (10%) – 12 (12%)
Good 7 (7%) – 9 (9%)
Fair 4 (4%) – 6 (6%)
Poor 0 (0%) – 3 (3%)

Is the assessment supported by the subjective and objective information? Why or why not?–

Excellent 14 (14%) – 16 (16%)

Good 11 (11%) – 13 (13%)

Fair 8 (8%) – 10 (10%)

Poor 0 (0%) – 7 (7%)

What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?–

Excellent 18 (18%) – 20 (20%)

Good 15 (15%) – 17 (17%)

Fair 12 (12%) – 14 (14%)

Poor 0 (0%) – 11 (11%)

·   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.–

Excellent 23 (23%) – 25 (25%)

Good 20 (20%) – 22 (22%)

Fair 17 (17%) – 19 (19%)

Poor 0 (0%) – 16 (16%)

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.–

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3 (3%) – 3 (3%)

Poor 0 (0%) – 2 (2%)

Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation–

Excellent 5 (5%) – 5 (5%)
Good 4 (4%) – 4 (4%)
Fair 3 (3%) – 3 (3%)
Poor 0 (0%) – 2 (2%)

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.–

Excellent 5 (5%) – 5 (5%)
Good 4 (4%) – 4 (4%)
Fair 3 (3%) – 3 (3%)
Poor 0 (0%) – 2 (2%)

Total Points: 100

Name: NURS_6512_Week_6_Assignment_1_Rubric

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)

 
 

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

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.

By Day 7 of Week 6