Introduction and Pre-brief
Mrs. Esther Park is a 78-year-old woman who comes to the clinic complaining of abdominal pain. She reports that the pain isn’t severe, but that her daughter was concerned and brought her in. It is very important to determine whether or not the situation is an emergency and the underlying cause of Esther’s discomfort. Be sure to inquire about a variety of psychosocial factors related to the GI system, including her diet, toilet habits, immunizations, recent travel, etc. This case study will offer you the opportunity to take a complete surgical, reproductive, and current sexual history. During her physical examination, take particular note as to where Mrs. Park verbalizes pain during palpation so that you may synthesize verbal and non-verbal cues. Be sure to apply the supportive information learned in this week’s concept lab to your critical thinking process in this case study.
Evaluation of the elderly patient with abdominal pain can be difficult, time-consuming, and fraught with potential missteps. Abdominal pain is the most common emergency department complaint and the fourth most common complaint among elderly patients. The physiologic, pharmacologic, and psychosocial aspects of elderly patients make an evaluation of their abdominal pain different than in the general population.
As a clinician, you must develop an index of suspicion which is defined as awareness and concern for potentially serious underlying and unseen injuries or illness. Having a well-developed index of suspicion for abnormality will help to differentiate diagnoses.
To optimize your assessment experience and sharpen your skills, be sure to explore the Abdominal Concept Lab prior to beginning the assignment.
The purposes of the Shadow Health Physical Assessment Assignments are to: (a) increase knowledge and understanding of advanced practice physical assessment skills and techniques, (b) conduct focused and comprehensive histories and physical assessments for various patient populations, (c) adapt or modify your physical assessment skills and techniques to suit the individual needs of the patient, (d) apply assessment skills and techniques to gather subjective and objective data, (e) differentiate normal from abnormal physical examination findings, (f) summarize, organize, and appropriately document findings using correct professional terminology, (g) practice developing primary and differential diagnoses, (h) practice creating treatment plans which include diagnostics, medication, education, consultation/referral, and follow-up planning; and (i) analyze and reflect on own performance to gain insight and foster knowledge.
Activity Learning Outcomes
Through this assignment, the student will demonstrate the ability to:
- Apply knowledge and understanding of advanced practice physical assessment skills and techniques (CO1)
- Perform focused and comprehensive histories and physical assessments for various patient populations (CO4 and CO5)
- Adapt skills and techniques to suit the individual needs of the patient (CO4)
- Differentiate normal from abnormal physical examination findings (CO2)
- Summarize, organize, and document findings using correct professional terminology (CO3)
Sunday 11:59 PM MT at the end of each respective week.
Students are expected to submit assignments by the time they are due. Assignments submitted after the due date and time will receive a deduction of 10% of the total points possible for that assignment for each day the assignment is late. Assignments will be accepted, with penalty as described, up to a maximum of three days late, after which point a zero will be recorded for the assignment.
In the event of an emergency that prevents timely submission of an assignment, students may petition their instructor for a waiver of the late submission grade reduction. The instructor will review the student’s rationale for the request and make a determination based on the merits of the student’s appeal. Consideration of the student’s total course performance to date will be a contributing factor in the determination. Students should continue to attend class, actively participate, and complete other assignments while the appeal is pending.
Total Points Possible: 75 Points
Step One: Complete the designated Shadow Health (SH) Assignment on the SH platform.
Step Two: Document your findings on theor the .
Step Three: Upload the Lab Pass and completed SOAP Note as separate documents to the same assignment tab in the gradebook.
NOTE: Before initiating any activity in Shadow Health, complete the required course weekly readings and lessons as well as review the introduction and pre-brief.
- Complete the Shadow Health Concept Lab (Weeks 2, 4, and 5) prior to beginning the graded assignment.
- Gather subjective and objective data by completing a focused, detailed health history and physical examination for each physical assessment assignment.
- Critically appraise the findings as normal or abnormal.
- Complete the post activity assessment questions for each assignment .
- Complete all reflection questions following each physical assessment assignment.
- Digital Clinical Experience (DCE) scores do not round up. For example, a DCE score of 92.99 is a 92, not a 93.
- You have a maximum of two (2) attempts per Shadow Health assignment to improve your performance. However, you may elect not to repeat any assignment. NOTE: If you repeat an attempt, ONLY the second attempt will be graded, regardless of the DCE score. Please refer to the grading rubric categories for details.
- Download the Lab Pass for the final attempt on the assignment.
On the Canvas Platform:
- Summarize, organize, and appropriately document findings using correct professional terminology on the SOAP Note Template.
- Identify three (3) differential diagnoses and provide ICD-10 codes and pertinent positive and negative findings for each diagnosis.
- Create a comprehensive treatment plan for each assignment. Must address the following components: Diagnostics, Medication, Education, Referral/Consultation, and Follow-up planning. If no interventions for one or more component, document “none at this time” but do not skip over the component.
- Provide rationales and citations for diagnoses and interventions.
- Include at least one scholarly source to support diagnoses and treatment interventions with rationales and references on the SOAP note. Only scholarly sources are acceptable for citation and reference in this course. These include peer-reviewed publications, government reports, or sources written by a professional or scholar in the field. The textbooks and lessons are NOT considered to be outside scholarly sources. For the threaded discussions and reflection posts, reputable internet sources such as websites by government agencies (URL ends in .gov) and respected organizations (often ends in .org) can be counted as scholarly sources. The best outside scholarly source to use is a peer-reviewed nursing journal. You are encouraged to use the Chamberlain library and search one of the available databases for a peer-reviewed journal article. The following sources should not be used: Wikipedia, Wikis, or blogs. These websites are not considered scholarly as anyone can add to these. Please be aware that .com websites can vary in scholarship and quality. For example, the American Heart Association is a .com site with scholarship and quality. Each student is responsible for determining the scholarship and quality of any .com site. Ask your instructor before using any site if you are unsure. Points will be deducted from the rubric if the site does not demonstrate scholarship or quality. Current outside scholarly sources must be published with the last 5 years. Instructor permission must be obtained BEFORE the assignment is due if using a source that is older than 5 years.
- Upload the Lab Pass to the appropriate assignment area in Canvas Grades
Information the patient or patient representative told you
SOAP Note Template
|Initials: E.P||Age: 78||Gender: Female|
|157 cm||54.5 kg||110/70||92||16||37.0C||99%||6/10||Medication: No known medication allergies
Food: No known food allergies LATEX ALLERGEY- contact dermatitis
Environment: No known environmental allergies
|History of Present Illness (HPI)|
|Chief Complaint (CC)||Pain in lower abdomen and is having difficulty going to the bathroom||CC is a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom|
|Onset||General discomfort started 5 days ago
Difficulty having a BM also started 5 days ago
Last BM was a few days ago where she stated having “digestive upset” and had diarrhea. Patient states, “diarrhea came out of nowhere” and only lasted 1 day. Unable to have BM for 3 days.
|Location||Pain is in lower abdomen
Pain does not radiate.
|Duration||Pain is all the time, states there is not a period when she is not in pain. Patient states her diarrhea lasted for only a day and she had “a few bouts over a day.” Patient states unable to have BM for 3 days.|
|Characteristics||Describes pain as “dull and crampy” and does not radiate. States that it is a 6/10. Patient states that she has noticed some bloating.|
|Aggravating Factors||Physical activity and eating makes pain and bloating worse. Patient states she cannot eat more than a few bites before the pain is worse.|
|Relieving Factors||Patient states resting and trying not to move helps with her pain, but the pain is still there. Patient states take small sips of warm water that was suggest by a friend and it did not help.|
|Treatment||Patient denies taking anything for abdominal pain.|
|Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.|
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