NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN

Walden University NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN– Step-By-Step Guide

This guide will demonstrate how to complete the Walden University NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN

Whether one passes or fails an academic assignment such as the Walden University NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN

The introduction for the Walden University NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN

After the introduction, move into the main part of the NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN

Abdominal Assessment  

Abdominal problems have adverse effects on the health and wellbeing of the patients. Nurses are expected to utilize their knowledge and skills in comprehensive history taking and patient assessment to develop accurate diagnoses and treatment plans for their patients. Therefore, this paper is an examination of J.R’s case study. J.R is a 47-year-old client that has come to the hospital with generalized abdominal pain for the last three days and nausea. The purpose of this paper is to examine the additional subjective and objective information to be obtained from the client, whether the case study has subjective and objective data, diagnostic investigations, and decision related to the developed diagnosis.  

Analysis of Subjective Portion 

Subjective data relates to that obtained from the patient. It focuses on the experiences of the patient with the health problem. Additional subjective information should be obtained from the patient to come up with an accurate diagnosis and treatment plan. One of the subjective data that should be obtained from the client is quantification of the abdominal pain. Information about the pain rating, severity, character, and relieving, precipitating, and aggravating factors should be obtained. The other aspect of the pain should focus on whether the pain is generalized, radiating to other body parts, or increasing or decreasing in intensity. The pain should also be described in terms of whether it is sudden or gradual. 

Moreover, the nature of diarrhea that the client reports should also be quantified. A focus should be placed on aspects such as the frequency of the diarrhea in a given period to determine if they client is dehydrated or not. The additional information about diarrhea include color of stool, relieving, aggravating, and precipitating factors. The provider should also obtain information about the dietary history of the client. Food poisoning could be a factor to consider in this client’s case. As a result, information about recent dietary habits and perceived hygiene of the foods should be obtained to determine the cause of the problem. The hygiene status and source of water that the client drinks should be obtained to ascertain whether the problem is a water-borne disease. Since the client has history of gastrointestinal bleeding, it would be necessary to ask about recent changes in color, smell, and texture of the stool prior to the current problems (Jarvis & Eckhardt, 2019). Such information will aid in ruling out causes such as ulcers of the gastrointestinal system.  

Analysis of Objective Position 

Healthcare providers obtain objective data using methods such as observation, palpation, percussion, and auscultation. The data is important in confirming or validating the subjective data given by the patient. Additional objective data should be obtained from the client. They include the general appearance of the client during the first encounter with the healthcare provider. The healthcare provider should provide a description of the grooming, energy levels, body weight, and if the patient is dehydrated or not.  The provider should have also assessed the patient for hydration status and jaundice by checking on skin turgor and sclera for jaundice. The patient should have also provided comprehensive abdominal assessment to determine whether there is distention, bowel movements, organomegally, distention of veins, and scars. The provider should have also palpated the abdomen for tenderness, rigidity, or any rebound tenderness. The information could have helped rule out causes such as bowel obstruction and organomegally (Jarvis, 2019). The objective data could have facilitated the development of an accurate diagnosis for the client.  

Analysis of the Assessment 

Objective and subjective data support the assessment of JR. Examples of subjective data that supports the assessment include information about diarrhea, nausea, stomach pains, past medical, medication, allergies, family, and social histories. Examples of objective data include the vitals and heart, lungs, skin, and abdominal findings.  

Diagnostic Tests 

Stool test is the most appropriate diagnostic investigation for JR. Stool analysis should be performed to determine if the client has an infection or the cause could be due to gastrointestinal bleeding. Blood tests such as complete blood count are also recommended to determine if the client has low hemoglobin level due to bleeding or elevated white blood cell count to indicate infection. Since the client has a history of gastrointestinal bleeding, it would be appropriate to perform abdominal ultrasound to determine the actual cause of the problem (Jarvis & Eckhardt, 2019).  

Rejecting/Accepting the Diagnosis 

I would accept the current diagnosis. Patients with gastroenteritis experience symptoms similar to those of JR. The symptoms include abdominal cramps, vomiting, nausea, and diarrhea. The infection is short-term, implying symptom resolution over time. JR reports that the pain severity has declined, implying a potential symptom resolution in gastroenteritis. He also complains of diarrhea, abdominal pain, and nausea, hence, the decision to accept the diagnosis (Bányai et al., 2018). The differential diagnoses to be considered include abdominal obstruction, colon cancer, and inflammatory bowel disease. The above differentials have patients experiencing either nausea, vomiting, diarrhea, or abdominal pains. However, it may not be abdominal obstruction due to the presence of diarrhea and absence of abdominal distention. Diagnostic investigations such as abdominal ultrasound are needed to rule out colon cancer. The patient does not have any predisposition to environmental triggers, hence, ruling out inflammatory bowel disease (Guan, 2019).  

Also Read:

DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM

ASSESSING MUSCULOSKELETAL PAIN

CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS

DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM

Conclusion 

Subjective and objective data guide the diagnoses developed for health problems affecting patients. JR is likely to be suffering from gastroenteritis. Additional subjective and objective data is however needed to develop an accurate diagnosis. Diagnostic investigations should be used to develop accurate diagnosis for the patient.  

References 

Bányai, K., Estes, M. K., Martella, V., & Parashar, U. D. (2018). Viral gastroenteritis. The Lancet, 392(10142), 175–186. https://doi.org/10.1016/S0140-6736(18)31128-0 

Guan, Q. (2019). A Comprehensive Review and Update on the Pathogenesis of Inflammatory Bowel Disease. Journal of Immunology Research, 2019, e7247238. https://doi.org/10.1155/2019/7247238 

Jarvis, C. (2019). Physical Examination & Health Assessment Access Code. Elsevier Health Sciences. 

Jarvis, C., & Eckhardt, A. (2019). Physical Examination and Health Assessment. Elsevier. 

Sample Answer 2 for NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN

Gastrointestinal disorders are common encounters in nursing practice with considerable public health impacts. Nurses and other healthcare providers should perform comprehensive history taking and physical examinations to develop accurate diagnoses and care plans. Therefore, this essay examines J.R.’s case study. J.R. presented to the hospital with complaints of having generalized abdominal pain that began three days ago. He has been experiencing diarrhea that has been unresponsive to any treatments adopted by the patient.  The essay analyzes additional subjective and objective information that should be obtained from the client if subjective and objective data supports the assessment, diagnostic tests, and possible differential diagnoses.

Additional Subjective Information

  Additional subjective information should be obtained to guide the development of an accurate diagnosis. First, information about the things that might have led to the abdominal pain should be obtained. This includes data such as diet, alcohol consumption, or possible trauma that could have led to the symptoms. Information about previous experiences of stomach pain should also be obtained. A previous history of stomach pain will help the nurse determine if the condition is acute or chronic. In addition, the nurse should determine if JR experienced a similar pain when he experienced gastrointestinal bleeding four years ago. Information on previous treatments for the GI bleed should be obtained to guide the current management. The nurse should also seek information about the characteristics of stomach pain (Maret-Ouda et al., 2020). For example, information on whether the pain radiates elsewhere should have been obtained to rule out causes such as pancreatitis.

 Information about the character of the diarrhea should also be obtained. Information such as blood-stained diarrhea would help the nurse to develop a potential diagnosis of gastrointestinal tract bleeding. Associated symptoms such as vomiting should also be obtained. This is important because symptoms such as projectile vomiting will indicate potential problems such as pyloric stenosis. Information about changes in the client’s weight over the past few months should also be obtained. Unintentional weight loss could indicate other health problems such as cancer of the gastrointestinal system. Information on changes in appetite should also be sought. Early satiety could indicate problems such as hypertrophic pyloric stenosis. The nurse should also obtain information about the factors that relieve, precipitate, or worsen the stomach pain. For example, a diagnosis of peptic ulcer disease will be made if the symptoms worsen 15-30 minutes after eating (Sverdén et al., 2019). A diagnosis of gastroesophageal reflux disease will be made if the symptoms worsen when JR lies down and improves with sitting upright.

Additional Objective Information

The nurse should obtain additional objective information from JR to make an informed diagnosis and develop a patient-centered care plan. Firstly, information about JR’s general appearance should be documented. This includes information such as his grooming, weight, alertness, and orientation. A comprehensive review of all the body systems should have also been done. For example, the assessment of the respiratory system is inadequate. Information such as the presence or absence of nasal flaring, wheezes, crackles, rhonchi, and peripheral or central cyanosis should have been documented (Katz et al., 2022). The assessment of the cardiovascular system should have extended to information such as the presence or absence of jugular venous distention or peripheral edema.

The information in the assessment of the gastrointestinal system is inadequate. Additional information such as the presence or absence of abdominal scars, organomegaly, pulsations, ascites, and visible blood vessels should have been documented. This is important because information such as palpable abdominal pulsations would indicate aortic abdominal aneurysm. Information about any abdominal pain on palpation and the location of the pain should have also been obtained and pain rating on a pain rating scale.  The nurse should have also assessed the skin for capillary refill, turgor, cyanosis, and edema (Haque & Bhargava, 2022). Low capillary refill and poor skin turgor could indicate problems with circulation and hydration.

If Subjective and Objective Data Supports the Assessment

Subjective assessment data is the information a patient gives about their health problems. Subjective data supports JR’s assessment. Some of the subjective data include his chief complaints, history of the chief complaints, past medical history, medications, allergies, family, and social history. Objective data refers to the information that the healthcare provider obtains during assessment. Healthcare providers use methods such as inspection, palpation, percussion, and auscultation to obtain objective data (Malik et al., 2023). Objective data supports JR’s case study. Examples of objective data in the case study include vital signs and findings reported in the assessment of the heart, lungs, skin, and abdomen.

Appropriate Diagnostic Tests

Some diagnostic tests should be performed to develop JR’s accurate diagnosis. An occult stool test should be performed to determine if the client’s problem is due to an infection and rule out GI bleeding. A complete blood count test would also be performed to rule out an infection. Stool culture might also be performed to determine the accurate cause of JR’s problem. Antigen tests might also be performed to detect antigens associated with parasites and viruses that cause gastrointestinal problems such as gastroenteritis. A fecal fat test might be needed to rule out malabsorption problems in the client (Chen et al., 2021). Radiological investigations such as abdominal ultrasound and x-rays might be performed to rule out causes such as appendicitis and carcinoma.

Accepting or Rejecting the Current Diagnosis

I will accept the current diagnosis of left lower quadrant pain. The objective findings reveal the presence of left lower quadrant pain. This provisional diagnosis should guide the additional investigations performed to develop an accurate diagnosis. I also accept gastroenteritis as the other diagnosis for JR. Patients with gastroenteritis experience symptoms such as diarrhea, abdominal pain and cramping, nausea, vomiting, and loss of appetite (Chen et al., 2021).  JR has these symptoms; hence, gastroenteritis is his other provisional diagnosis.

Three Possible Differential Diagnoses

Diverticulitis is the first differential diagnosis that should be considered for JR. Diverticulitis is an inflammation of the sigmoid colon that causes left lower quadrant pain. The pain worsens when a patient eats. The accompanying symptoms include diarrhea, constipation, bloating, nausea, and the passage of bloodstained stool (Sugi et al., 2020). Diagnostic investigations will rule in or out diverticulitis as the cause of JR’s problems.

The second differential diagnosis that should be considered for JR is peptic ulcer disease. Peptic ulcer disease is a condition that develops from the destruction of the stomach wall lining by pepsin or gastric acid secretion. It affects the distal duodenum, lower esophagus, or jejunum. Patients often experience epigastric pain 15-30 minutes after a meal. A diagnosis of duodenal ulcer disease is made if the patient reports epigastric pain 2-3 hours after a meal (Malik et al., 2023; Sverdén et al., 2019). The additional symptoms that patients with peptic ulcer disease experience include bloating, abdominal fullness, nausea and vomiting, hematemesis, melena, and changes in body weight.

Gastritis is the last differential diagnosis that should be considered for JR. Gastritis develops from the inflammation of the gastric mucosa. Factors such as infections, smoking, taking too much alcohol, prolonged use of aspirin and non-steroidal anti-inflammatory medications, and immune-mediated reactions might cause gastritis. Patients who are affected by gastritis experience a range of symptoms. They include stomach pain or upset, hiccups, belching, abdominal bleeding, nausea and vomiting, feeling of fullness, loss of appetite, and blood in stool or vomitus (Maret-Ouda et al., 2020; Rugge et al., 2020). Therefore, additional investigations should be performed to develop JR’s accurate diagnosis and treatment plan.

Conclusion

In summary, JR’s subjective and objective data is inadequate. Additional subjective and objective data should be obtained to guide the treatment plan. Subjective and objective data supports JR’s assessment. I accept the current diagnosis of left lower quadrant pain and gastroenteritis.. Different diagnostic investigations should be performed to rule in and out different differential diagnoses in the case study. The three differential diagnoses that should be considered for JR include gastritis, peptic ulcer disease, and diverticulitis.

References

Chen, P. H., Anderson, L., Zhang, K., & Weiss, G. A. (2021). Eosinophilic Gastritis/Gastroenteritis. Current Gastroenterology Reports, 23(8), 13. https://doi.org/10.1007/s11894-021-00809-2

Haque, K., & Bhargava, P. (2022). Abdominal Aortic Aneurysm. American Family Physician, 106(2), 165–172.

Katz, P. O., Dunbar, K. B., Schnoll-Sussman, F. H., Greer, K. B., Yadlapati, R., & Spechler, S. J. (2022). ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. The American Journal of Gastroenterology, 117(1), 27–56. https://doi.org/10.14309/ajg.0000000000001538

Malik, T. F., Gnanapandithan, K., & Singh, K. (2023). Peptic Ulcer Disease. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK534792/

Maret-Ouda, J., Markar, S. R., & Lagergren, J. (2020). Gastroesophageal Reflux Disease: A Review. JAMA, 324(24), 2536–2547. https://doi.org/10.1001/jama.2020.21360

Rugge, M., Sugano, K., Sacchi, D., Sbaraglia, M., & Malfertheiner, P. (2020). Gastritis: An Update in 2020. Current Treatment Options in Gastroenterology, 18(3), 488–503. https://doi.org/10.1007/s11938-020-00298-8

Sugi, M. D., Sun, D. C., Menias, C. O., Prabhu, V., & Choi, H. H. (2020). Acute diverticulitis: Key features for guiding clinical management. European Journal of Radiology, 128, 109026. https://doi.org/10.1016/j.ejrad.2020.109026

Sverdén, E., Agréus, L., Dunn, J. M., & Lagergren, J. (2019). Peptic ulcer disease. BMJ, 367, l5495. https://doi.org/10.1136/bmj.l5495

NURS 6512 Assignment 1 Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System

Name: 

Section: 

Week 7                

Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation 

Name: Mr. J.M. Age: 38 years Sex: Male 

SUBJECTIVE DATA:  

Chief Complaint (CC): “I have sporadic chest pain” 

History of Present Illness (HPI): Mr. J.M. is a 38-year-old African American male who presented to the emergency department with complaints of sporadic chest pain for the last one month. The pain is usually centrally located and radiates to the left arm. He has experienced 3 episodes since the last month with each episode lasting several minutes. Currently, the pain is at 0 on a scale of zero to 10 although it is generally at 5 at its worst. The pain is characteristically uncomfortable and tight. It is aggravated by activities such as climbing stairs and yardwork while brief episodes of rest relieve the pain. He has not taken any medications for the pain. 

Medications: Reports taking Lopressor 100mg PO once daily for hypertension and Lipitor 20mg PO once daily for hyperlipidemia as well as fish oil 1000mg PO twice daily. 

Allergies: None 

Past Medical History (PMH): Reports hypertension and hypercholesterolemia. No previous hospitalizations or blood transfusions. Denies prior chest pain treatment. Poor blood pressure monitoring both at home. Denies regular blood pressure checks at the pharmacy and drug store. Reports a recent EKG test that was normal. His last visit to a healthcare provider was three months ago. 

Past Surgical History (PSH): No previous surgeries. 

Sexual/Reproductive History: Heterosexual. 

Personal/Social History: Has lived a relatively stress-free lifestyle. Regular water intake of about a liter per day. Drinks 2 cups of coffee daily. Denies routine regular physical activity and his last regular exercise was 2 years ago. Reports moderate alcohol consumption of about 2 to 3 drinks per week mostly on weekends but no tobacco or illicit drug use. His typical breakfast is a granola bar and instant breakfast shake, lunch turkey sub, and his dinner is typically grilled meat alongside vegetables.   

Immunization History: All immunization up to date. The last COVID-19 vaccine was February this year, the last Tdap was May 2022 and the last influenza was January 2022. 

Significant Family History: His mother is 65 years old and hypertensive while the father is 70 years old and obese. The grandmother died at 77 years due to a heart attack while the grandfather is 85 but suffered a stroke at 80 years. He has two daughters all alive and well.  

Review of Systems: 

General: Denies fever, changes in weight, chills, fatigue, night sweats, and palpitations. 

Cardiovascular/Peripheral Vascular: No edema, easy bruising, angina, or easy bleeding. 

Respiratory: No difficulty in bleeding, sputum, cough, or shortness of breath.  

Gastrointestinal: Denies alteration in bowel habits, abdominal pain and nausea, and vomiting 

Musculoskeletal: No back pains, joint pains, and muscle weakness. 

Psychiatric: No anxiety, depression, delusions, or hallucinations 

OBJECTIVE DATA:  

Physical Exam: 

Vital signs: Temperature- 98.5 F, pulse 80 beats per min, respiratory rate- 19 breaths per minute, blood pressure- 132/86 mmHg, saturation- 92% on room air, height 70. 86 inches, weight 251 lbs. BMI- 29. 

General: A young African American male, well kempt and groomed, and appropriate for his stated age. Not in any obvious distress, good body built and well hydrated. No pallor, finger clubbing, splinter hemorrhages, jaundice, cyanosis, lymphadenopathy, or peripheral edema. 

              Cardiovascular/Peripheral Vascular: Nondistended neck veins (JVP less than 4cm above sternal angle), right carotid pulse 3+ with a thrill and bruit, left carotid pulse 2+ with no thrill or bruit, right and left brachial and radial arteries pulses 2+ with no thrills, right and left femoral arteries pulses 2+ with no thrills and bruits, right and left popliteal arteries pulses 1+ with no thrills, right and left tibial and dorsalis pedis pulses 1+ with no thrills, no renal, iliac and abdominal aorta bruits, and capillary refill is less than 3 seconds in all the digits. Precordium is brisk and tapping. The point of maximal impulse is displaced laterally and less than 3 cm, with a heave but no thrill. S1, S2, and S3 were heard with gallops, no murmurs.  

Respiratory: Symmetric chest, moves with respiration with no obvious scars or masses on inspection. the trachea is central, with equal chest expansion, no tenderness or palpable masses, and equal tactile fremitus on palpation. Resonant on percussion. Good air entry and vesicular breath sounds in all lung zones, and no wheezes or rhonchi on auscultation. 

Gastrointestinal: Nondistended, moves with respiration, symmetric, normal contour and fullness, umbilicus everted and no visible distended veins, striae, or scars. No tenderness or palpable masses on light and deep palpation. The liver is palpable 2 cm below the right costal margin. Liver span 8 cm. Spleen and both kidneys are impalpable. Tympanic on percussion, no shifting dullness or fluid thrill. No friction rubs over the liver and spleen. 

Musculoskeletal: Normal muscle bulk, power of 5/5 in all muscle groups, normal reflexes, and range of movement across all joints.  

Neurological: GCS 15/15, oriented to time place, and person, all cranial nerves and sensation intact, no neurological deficits noted, good bladder and bowel function. 

Skin: No rashes, darkening, tenting, or nail changes. 

Diagnostic Test/Labs: An EKG was done which revealed a sinus rhythm with no ST changes. Other critical tests include cardiac biomarkers particularly, troponin T/I, CK-MB, and myoglobin to exclude myocardial injury (Harskamp et al., 2019). Lipid profile and random blood sugar are required to check the level of lipid control and exclude diabetes mellitus respectively. Additionally, LDH to assess for cell necrosis, BNP to exclude concurrent heart failure, and inflammatory markers especially CRP for prognostication. Similarly, complete blood count with differential, urea creatinine, and electrolytes as well as liver function tests are required as a baseline for medication. Imaging tests include a transthoracic echocardiogram to assess left ventricular function, detect any wall motion abnormalities and identify any complications (Harskamp et al., 2019). Finally, a cardiac CT with IV contrast may be required to rule out differentials such as pulmonary embolism and aortic dissection. 

ASSESSMENT:  

Mr. J.M. is a 38-year-old African American male, known patient with hyperlipidemia and hypertension who presents with complaints of sporadic centrally located chest pain that radiates to the left arm. The pain is usually aggravated by exertion but relieved by rest with a history of physical inactivity. On examination, the right carotid artery pulse is increased with a bruit and thrill, the apex is displaced laterally, and S1, S2, and S3 are heard with gallops but no murmurs. 

Main Diagnosis- The primary diagnosis is stable angina. Mr. J.M. presents with retrosternal chest pain that is tight and uncomfortable and that radiates to the left arm. This is characteristic of angina. However, these symptoms are worsened by exertion but relieved by rest which is a distinct feature of stable angina (Rousan & Thadani, 2019). According to Rousan and Thadani (2019), atherosclerosis is the most common etiology of this condition. Mr. J.M. has classic risk factors for atherosclerosis including arterial hypertension, hyperlipidemia, alcohol consumption, and overweight as well as a family history of cardiovascular events.  

Differential diagnosis 

Non-ST segmented elevated myocardial infarction- Myocardial infarction refers to an acute myocardial injury caused ischemia that results in tissue necrosis. This condition also presents with a retrosternal chest pain that dull and tight, precipitated by exertion and radiates to the left arm, shoulder, neck or jaw. Myocardial infarction may also be precipitated by an atherosclerotic event. However, lack of ST changes on EKG suggests NSTEMI (Cohen & Visveswaran, 2020).  

Hypertension and hyperlipidemia- Mr. J.M. has previous history of hypertension on metoprolol and hyperlipidemia on Lipitor. Furthermore, lateral displacement of the apex beat as well as a heave suggest left ventricular hypertrophy which is usually a consequence of arterial hypertension (Oparil et al., 2018). 

References 

Cohen, M., & Visveswaran, G. (2020). Defining and managing patients with non-ST-elevation myocardial infarction: Sorting through type 1 vs other types. Clinical Cardiology, 43(3), 242–250. https://doi.org/10.1002/clc.23308 

Harskamp, R. E., Laeven, S. C., Himmelreich, J. C., Lucassen, W. A. M., & van Weert, H. C. P. M. (2019). Chest pain in general practice: a systematic review of prediction rules. BMJ Open, 9(2), e027081. https://doi.org/10.1136/bmjopen-2018-027081 

Oparil, S., Acelajado, M. C., Bakris, G. L., Berlowitz, D. R., Cífková, R., Dominiczak, A. F., Grassi, G., Jordan, J., Poulter, N. R., Rodgers, A., & Whelton, P. K. (2018). Hypertension. Nature Reviews. Disease Primers, 4(1), 18014. https://doi.org/10.1038/nrdp.2018.14 

Rousan, T. A., & Thadani, U. (2019). Stable angina medical therapy management guidelines: A critical review of guidelines from the European Society of Cardiology and National Institute for Health and Care Excellence. European Cardiology, 14(1), 18–22. https://doi.org/10.15420/ecr.2018.26.1 

NURS 6512 Week 9 SH Comprehensive SOAP Note Documentation Template

Week 9 

Shadow Health Comprehensive SOAP Note Template 

Patient Initials: J. L Age: 28 Gender: Female 

SUBJECTIVE DATA: 

Chief Complaint (CC): “I came in because I’m required to have a recent physical exam for the health insurance at my new job.” 

History of Present Illness (HPI): No present illness. The patient is currently doing well. 

J.L is a 28-year-old African American female who presents for a pre-employment physical after securing employment at Smith, Stevens, Stewart, Silver & Company, a requirement prior to commencement. She denies any acute concerns today. Following her annual gynecological exam during Her last healthcare visit 4 months ago at Shadow Health General Clinic, she was diagnosed with polycystic ovarian syndrome and was initiated on oral contraceptives which she has well tolerated. She also has type 2 diabetes, well-controlled with diet, exercise, and metformin, which she just started 5 months ago. Currently no medication adverse effects. She states that she feels healthy, takes care of herself better than in the past, and looks forward to beginning the new job. 

Medications:  

• Drospirenone and Ethinyl estradiol PO QD (last use: this morning) 

• Metformin, 850 mg PO BID (last use: this morning)  

• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) 

• Acetaminophen 500-1000 mg PO prn (headaches)  

• Ibuprofen 600 mg PO TID PRN (menstrual cramps: last taken 6 weeks ago) 

• Albuterol 90 mcg/spray MDI 2 puffs Q4H PRN (last use: three months ago). 

Allergies: Allergic to cats and dust, causes sneezing, swelling of eyes, itchiness, runny nose, and breathing difficulties exacerbating her asthma symptoms. She reports a rash after taking penicillin. She denies food and latex allergies. 

Past Medical History (PMH): She has type 2 diabetes, diagnosed at 24 years, that is well controlled by metformin, diet, and exercise. A history of hypertension that normalized following initiation of exercise and dietary measures. Asthmatic since 2 and a half years old, on albuterol and fluticasone. Her last hospitalization was while in high school due to asthma. The latest asthma exacerbation was 3 months ago and resolved with the inhaler use. Daily blood sugar monitoring with average readings around 90 mg/dl. 

Past Surgical History (PSH): No previous surgeries. No history of blood transfusion. 

Sexual/Reproductive History: Menarche at 11 years, sexual debut at 18 years, heterosexual, and her LMP was a fortnight ago. She was diagnosed with PCOS four months ago. A regular cycle of 28 days for the last four months after being initiated on combined oral contraceptives. Her menses last five days with moderate bleeding. She is in a new male relationship and has yet to initiate sexual contact. Negative for HIV/AIDS and STIs (last test four months ago). 

Personal/Social History: Single, no children, stays with her mother and sister in a single-family home. She enjoys reading, attending Bible study, volunteering in church, and dancing. Also enjoys hanging out with friends 2-3 times per month during which she uses alcohol but not more than 3 drinks per episode. History of cannabis use from 15 to 21 years. However, no use of illicit drugs or tobacco. Ordinary breakfast is a frozen fruit smoothie with unsweetened yogurt, lunch is low-fat pita or vegetables on brown rice or sandwich on wheat bread while dinner is vegetables with a protein. She takes carrot sticks or an apple as a snack. Denies coffee intake but takes 1-2 diet sodas per day. Participates in mild to moderate exercises four to five times weekly. No pets or recent travel. 

Health Maintenance: She sees her primary care physician as scheduled. Does regular exercises and she is compliant with her medication. Her diet is as recommended by her dietician. Her last pap smear was 4 months ago, her last PPD was 2 years ago (negative), her last eye exam 3 months ago and her last dental exam was 5 months ago. Uses sunscreens. 

Immunization History: Received all the childhood vaccines according to the immunization schedule. Has also received the meningococcal vaccine for college as well as a tetanus booster last year. However, influenza and human papillomavirus vaccines have not been received.  

Significant Family History: Her mother is 50 years old, and has hypertension and high cholesterol levels. Father passed on last year aged 58 years following a car accident although he had type 2 diabetes, hypertension, and high cholesterol levels. Her brother is 25 years, overweight while her sister is 14 years and asthmatic. Maternal grandfather and grandmother died at 78 and 73 years respectively due to stroke. Both had hypertension and elevated cholesterol levels. Her paternal grandfather had type 2 diabetes although he passed on at 65 years due to colon cancer while her paternal grandmother is alive, 82 years but hypertensive. Her paternal uncle has alcohol use disorder. Otherwise, there is no family history of sickle cell disease, kidney disease, mental illness, other cancers, or sudden death. 

Review of Systems:  

General: No weight loss, fever, chills, and night sweats 

HEENT: Atraumatic.  No headaches, vision changes, eye pain, dryness, itchy or red eyes. Uses corrective lenses and visits optometrist (last visit 3 months ago). Reports no problem with hearing, ear pain, or discharge. Reports no alteration in sense of smell, sinus pain, sneezing, epistaxis, or rhinorrhea. No alterations in taste sensation, dry mouth, pain, sores, gum, jaw, or tongue abnormalities. No dental issues (last dental visit 5 months ago), hoarseness, sore throat, dysphagia, or swollen nodes.  

Respiratory: No chest pain, dyspnea, cough, sputum, or wheezing. 

Cardiovascular/Peripheral Vascular: No palpitations, edema, orthopnea, paroxysmal nocturnal dyspnea, tachycardia, or easy bruising. 

Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, excessive flatulence, food intolerance, and abdominal pain,  

Genitourinary: Denies vaginal discharge, itchiness, dysuria, flank pain, hematuria, nocturia, and polyuria. 

Musculoskeletal: No joint pain, muscle pain, muscle swelling, or joint stiffness. 

Neurological: Denies dizziness, lightheadedness, seizures, sense of disequilibrium, tingling sensation, or loss of coordination. 

Psychiatric: Denies depression, anxiety, or suicidal ideation. Reports decreased stress and improved sleep. 

Skin/hair/nails: Reports improvement of acne, facial and body hair. Reports a few moles and cessation of darkening of the skin around her neck. Denies nail changes. 

OBJECTIVE DATA:  

Physical Exam: 

Vital signs: Blood pressure- 128/82 mmHg, heart rate- 78 beats/min, respiratory rate- 15 breaths/min, temperature-99.0 F, saturation- 99% on room ar.  

Weight: 170cm 

Height: 84 kg 

BMI: 29.0 

Blood glucose: 100 mg/dl 

General: A young African American lady, well-groomed and kempt, not in any form of distress, well-hydrated, and well-nourished. No central or peripheral cyanosis, no pallor, no jaundice, no cervical, inguinal or axillary lymphadenopathy. No peripheral edema. 

HEENT: Normocephalic and atraumatic head. Eyes bilaterally present with equal hair distribution on eyebrows and lashes. No lid lesions, ptosis, or edema. Pink conjunctiva and white non-icteric sclera. Pupils are equal, round, reacting to light and accommodation bilaterally. Extraocular movements equal bilaterally, with no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no retinal hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. Tympanic membrane intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. The nasal mucosa is moist and pink with a midline septum. Moist oral mucosa without ulcerations or lesions, uvula rises midline on phonation. Intact gag reflex. Dentition without evidence of caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy. 

Neck: Soft, no tenderness, masses, or jugular venous distension. Non-rigid with a full range of motion. No lymphadenopathy. 

Chest/Lungs:  

Inspection: Chest moves with respiration symmetrically, no scars, visible lesions, or masses on the anterior and posterior aspects. 

Palpation: Non-tender, equal tactile fremitus bilaterally. 

Percussion: Resonant throughout.  

Auscultation: Equal air entry bilateral, vesicular breath sounds, no wheezes, cough, and crackles bilaterally. Equal vocal fremitus. 

Spirometry: FVC3.91L, FEV1/FVC ratio 80.56% 

Heart/Peripheral Vascular: Normoactive precordium, PMI in the fifth intercostal space left midclavicular line. Regular heart rate, S1 and S2 clear and distinct, no murmurs, rubs, gallops, heaves, lifts, or thrills. Equal bilateral carotid pulses 3+, no bruits or thrills. Equal bilateral peripheral pulses 2+, no bruits or thrills. Capillary refill is 2 seconds in all the digits. No peripheral edema. 

Abdomen: 

Inspection: A protuberant symmetric abdomen, moving with respiration, umbilicus everted, no visible masses, scars, or lesions. Coarse of hair pubis to the umbilicus. 

Auscultation: Normoactive bowel sounds in all the quadrants, no bruits over renal, aortic, or iliac arteries. 

Palpation: Warm and soft to touch, no masses, no tenderness or guarding, the liver edge is 1 cm below the right costal margin. The spleen and bilateral kidneys are impalpable. 

Percussion: Tympanic throughout. 

Genital/Rectal: Clean external genitalia, normal shape and color of labia majora and minor, and no discharges. Vaginal mucosa looks, moist, wet, and pink with no signs of inflammation. No cervical motion tenderness. No hemorrhoids or anal fissures, intact anal tone. 

Musculoskeletal: Full range of motions across all joints, power of 5/5 in all muscle groups of both upper and lower limbs. DTR +2, no deformity, CVA tenderness, masses, swelling, or pain with movement. 

Neurological: Alert, GCS 15/15, oriented to time, place, and person, intact short term, intermediate and long-term memory, coherent and appropriate speech, good intelligence, all cranial nerves intact. Good bulk, normotonia, power 5/5 in all muscle groups of both upper and lower limbs, deep tendon reflexes 2+ and equal bilaterally in both upper and lower limbs. Crude touch, vibration, temperature, and proprioception sensations are intact in all dermatomes. Normal stereognosis. Light touch is normal in all dermatomes except bilateral plantar surfaces. Cerebellar function: normal finger nose, rapid alternating movements, and heel to shin tests. Steady gait. Normal graphesthesia. Good bowel and bladder function, no spinal tenderness. 

Skin: Normal scalp skin, scattered pustules on the face. Facial hair on the upper lip, Acanthosis nigricans on the posterior neck. An old scar on the left shin. Free nail ridges.  

Diagnostic results:  

ASSESSMENT:  

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.