Accurate history taking of abdominal, urological, and gynecological complaints is essential for completing an assessment of the older adult. For this Assignment, as you examine this week’s patient case study, consider how you might evaluate and treat older adult patients who present with health concerns related to the abdominal, urological, or gynecological systems.
To prepare:
- Review the case study provided by your Instructor.
- Reflect on the patient’s symptoms and aspects of disorders that may be present.
- Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
- Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
- Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
- Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
- Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
- Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
- Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
- Learning resourses
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Kennedy-Malone, L., & Groenke-Duffy, E. (2023). Gastrointestinal disorders. In Advanced practice nursing in the care of older adults (3rd ed., pp. 268-323). F.A. Davis.
- Kennedy-Malone, L., & Groenke-Duffy, E. (2023). Renal and urological disorders. In Advanced practice nursing in the care of older adults (3rd ed., pp. 324-349). F.A. Davis.
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Kennedy-Malone, L., & Groenke-Duffy, E. (2023). Gynecological disorders. In Advanced practice nursing in the care of older adults (3rd ed., pp. 350-366). F.A. Davis.
- Demarest, L. (2019). Gotta go right now: What’s overactive bladder?Links to an external site. Nursing Made Incredibly Easy!, 17(4), 11–14. https://doi.org/10.1097/01.NME.0000559586.35631.37
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Jackson, P., & Vigiola, C. M. (2018). Intestinal obstruction: Evaluation and managementLinks to an external site.. American Family Physician, 98(6), 362–367.
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Shian, B., & Larson, S. T. (2018). Abdominal wall pain: Clinical evaluation, differential diagnosis, and treatmentLinks to an external site.. American Family Physician, 98(7), 429–436.
Listed below is a case study.
Note: When completing your focus notes, list your primary diagnosis and 3 differential diagnoses with evidence-based rationales.
Mr. Max Fisher is an 77-year-old male presenting to the office after having several days of
abdominal pain. He lives independently in his home of 45 years. He has been a widow for 3
years and now lives alone.
CC: “I have stomach pain.”
HPI: Max started feeling pain in his abdomen 3 days ago. He generally has normal, regular
bowel movements. He has been experiencing cramping abdominal pain, nausea and now some
vomiting.
abdominal pain. He lives independently in his home of 45 years. He has been a widow for 3
years and now lives alone.
CC: “I have stomach pain.”
HPI: Max started feeling pain in his abdomen 3 days ago. He generally has normal, regular
bowel movements. He has been experiencing cramping abdominal pain, nausea and now some
vomiting.
PMH: gastroesophageal reflux disease (GERD), hypertension (HTN), and a pacemaker placed 10
years ago for third-degree heart block. He presents today with a complaint of abdominal pain.
You suspect a bowel obstruction in Max, with complaints of cramping abdominal pain, nausea,
and vomiting for 3 days.
Describe six (6) ROS questions you would explore further with him to determine the location,
severity, and timing of his pain.
PE: The abdomen appears distended; Max has generalized tenderness over the epigastric
region on palpation. He is guarding so the exam is limited. Bowel sounds are decreased.
His vital signs are normal. He describes his abdominal pain as 7/10.
As the APRN, you order an abdominal x-ray. RESULTS: The abdominal x-ray is indeterminate.
What are your next diagnostic choices to determine a bowel obstruction in this patient?
List at least three differential diagnoses for abdominal pain in your SOAP note.
The CT scan shows that Max has a small bowel obstruction. What is your next step?
years ago for third-degree heart block. He presents today with a complaint of abdominal pain.
You suspect a bowel obstruction in Max, with complaints of cramping abdominal pain, nausea,
and vomiting for 3 days.
Describe six (6) ROS questions you would explore further with him to determine the location,
severity, and timing of his pain.
PE: The abdomen appears distended; Max has generalized tenderness over the epigastric
region on palpation. He is guarding so the exam is limited. Bowel sounds are decreased.
His vital signs are normal. He describes his abdominal pain as 7/10.
As the APRN, you order an abdominal x-ray. RESULTS: The abdominal x-ray is indeterminate.
What are your next diagnostic choices to determine a bowel obstruction in this patient?
List at least three differential diagnoses for abdominal pain in your SOAP note.
The CT scan shows that Max has a small bowel obstruction. What is your next step?
Assignment_Rubric
10 to >9.0 pts
Excellent
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.
0 to >9.0 pts
Excellent
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
25 to >23.0 pts
Excellent
The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.
Excellent
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.
10 to >9.0 pts
Excellent
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.
5 to >4.0 pts
Excellent
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.