Assessment of the Abdomen and Gastrointestinal System

Week 6 – The Episodic note case study: Abdominal Assessment

Week_6-Assessment of the Abdomen and GI System.pdf

Review the Episodic note from the case study that you have been provided for this week’s Assignment. 

• 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 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 three different references from current evidence-based literature.   The textbook is not considered an EBP source.

This should be written as a narrative/paragraphs only!

DO NOT rewrite a SOAP note. Tell me whats wrong with the attached one, do this in paragraph form. You will do this by answering the aforementioned questions.

Use subheadings for the 5 Questions