Description
A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CT scan. The CT scan revealed a growth on the pancreas, which turned out to be pancreatic cancerthe real cause of the cramping.
Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen.
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.
To Prepare
Review the Episodic note case study your instructor provides you for this weeks 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 weeks 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 patients 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.
By Day 7 of Week 6
- Submit your Lab Assignment.
- rubric
- 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.
