Analyze a SOAP 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.
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, hyperctive bowel sounds, pos pain in the LLQ
Diagnostics: None
ASSESSMENT:
Left lower quadrant pain
Gastroenteritis
To prepare:
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.
To complete:
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.
Sample Solution
In 1902 a younger African man in Bulawayo, stated by the call of Charlie, was located responsible of having raped the white eu woman, Ada Flower. The trial marked the beginning of an difficult to understand episode in Southern Rhodesian records, habitually known as the ‘black peril’. all through 3 decades, black African men, including Charlie have been vilified, regularly without enough evidence as being rapists. at the same time as similar ‘black peril’ scares have been skilled somewhere else, the Southern Rhodesian moral panics reached specific depth, and endured for a huge time frame. causes of the phenomenon have gone through giant transformations; Ronald Hyman’s announcement that ‘black peril’ turned into a symptom of the ‘loss of sexual field amongst black guys’ , has lengthy been assailed by using the overpowering proof that the scares did no longer correlate with tangible reality. more recent studies classify the hysteria as a form of white psychopathology. figuring out the psychosomatic man or woman of ‘black peril’ has, but, opened up new limitations for the historian. The non-public nature of inner thoughts makes the assessment of the volume to which people have been ‘inclined’ hard. The technique superior here is to research collective psychologies, seen as the end result of specific demographic, political, and monetary factors, which cultivated a mainly traumatic environment. In these situations, efforts to set up a white settler society and construct a specifically Southern Rhodesian identification, had been in anxiety with the consistent and speedy ‘evolution of each white and black society’. As future fears became present realities, racial, gender and sophistication identities have been constantly thrown into flux. ‘Black peril’, become not however, unmarried or homogenous. instead the idea became multifaceted and heterogeneous in form. ‘Black peril’, as increasingly a part of broader political debates turned into infused with wider discourses, rendering it susceptible to the political and social orientation of its perceivers. This tendency of the hysteria to ‘spill over borders’ well-knownshows each the range of historical actors concerned and the capacity subjectivity of ‘black peril’, raising new ambiguities. This paper therefore builds at the expertise of electricity superior by using Michael Foucault inside the Sixties to boost an interpretation of the complex combination of factors and members which contributed to ‘black peril’ scares in Southern Rhodesia. within the pages that comply with, it will likely be argued that at the same time as white settlers from all agencies inside Southern Rhodesia’s numerous social economy could succumb to ‘black peril’ worry, the white community turned into no longer homogenous, nor can the idea of them being ‘prone’ provide an explanation for why the hysteria became so severe. as an alternative, numerous but interrelated anxieties approximately the destiny protection of the settler community sustained ‘black peril’ narratives, as a device thru which the evolution of settler society, and assumed gender, racial and sophistication identities can be mediated. even as the Southern Rhodesian ‘black peril’ drew on common subject matters, it changed into unique in each its form and intensity. ‘Black peril’ became inextricably related with the fear of African adult males molesting ecu females. The confidential record written via Superintendant Brundell of the crook investigation branch in Bulawayo, 1915, described the ‘black peril’ as ‘any rape or assault with intent to dedicate rape with the aid of an African on a white woman…for the reason of thrilling or fulfilling bestial goals,’ highlighting regular european assumptions approximately Africans’ ‘uncivilised’ state. In 1906, arguing that the ‘black peril’ became approximately the whether or not the white man might continue to be ‘paramount’, the explorer and dealer Stanley Hyatt, with his wide experience of Southern African colonies, quantified the issue as ‘the best hassle of all…to the destiny prosperity of the extremely good subcontinent.’ Hyatt encapsulates the predicament of the settler society, whose ‘presence…on African s>
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