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Assessing the AbdomenAbdominal pain has proven to be a major issue facing emergency room doctors since the diagnosis process is relatively complex. Meisel (2011) contends that doctors in emergency rooms do not fancy diagnosing and treating abdominal pain because it entails dealing with bodily fluids, complex internal examinations, and a wide range of diagnostic tests and therapies. This comes at a time when abdominal pain is one of the major reasons American patients visit the emergency room (ER). Caring for abdominal pain is characterized by a high chance of misdiagnosis unlike other health issues. ER doctors are faced with challenging and time-consuming processes when trying to determine the actual cause of abdominal pain. This is a case study of a woman who visited an emergency room for severe abdominal pain and was diagnosed with diverticulitis. The case study entails an analysis of SOAP (Subjective, Objective, Assessment, and Plan) factors in describing abnormal findings relating to the woman’s condition.
Case Analysis
Diagnosis of a patient’s abdominal pain or cramping is a complex process that requires consideration of various factors that could be contributing to the pain. In this case study, information regarding the patient’s abdominal pain has been provided using the SOAP framework. This framework is commonly used in clinical settings to help describe abnormal findings relating to a patient’s condition. For this case study, SOAP was utilized to help identify abnormal issues relating to the individual’s abdominal pain. The information provided through this technique can be utilized to help nurses prepare themselves to better diagnose conditions in the abdomen. This use of this technique in abdominal assessment also involved collecting information regarding the patient’s history as well as conducting physical examinations and diagnostic tests.
Subjective Portion of the Note
An important part in accurate diagnosis of a patient...
According to Macaluso & McNamara (2012), collection of the patient’s history should incorporate a complete description of his/her pain as well as medical, social, and surgical information. Based on the subjective portion of the note provided relating to this patient’s condition, the patient’s history, medical, and social information was collected. Additionally, the subjective portion of the note provides a description of the extent of abdominal pain. However, the description does not include information regarding the exact location of the abdominal pain, its associating symptoms, and aggravating factors. Therefore, additional information that should be included in the subjective portion of the note include the precise location of the pain, its associating symptoms, alleviating factors, and aggravating factors. Such information is usually critical when describing a history of the present illness (HPI) and helps in determining a proper diagnosis for the condition.
Objective Portion of the Note
The objective portion of the note provides information relating to the vital signs of the patient’s abdominal pain. Moreover, the clinician has also included information about the individual’s physical assessment results under the objective section. However, the subjective portion of the note lacks some important information that would help in proper diagnosis of the patient’s situation. Some additional information that should be included in the documentation under the objective section include physical assessment results relating to eyes, ears, nose, throat or mouth, lymph nodes, and extremities. This information is essential to help in understanding the associated symptoms of the abdominal pain as well as its alleviating or aggravating factors, which is vital during diagnosis.
Assessment
Based on information from the subjective and objective portions of the note,…
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