Your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format.

Case 2: Gastrointestinal Pain

A 50-year-old male complains of burning pain starting at the abdomen and rising to the middle of his chest. He describes the pain as a gnawing feeling that begins after meals, especially when lying down.

Case 3: Nausea and Vomiting

 A 20-year-old female complains of nausea and has vomited three times over the past 48 hours. The patient also experienced a low-grade fever this morning. She states that she recently ate shellfish at a new restaurant with two friends who are suffering from similar symptoms.

To prepare:

With regard to the case study you were assigned:

•Review this week’s 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 you were assigned.

•Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s 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.

POST 1 TO 2 PAGES SOAP NOTE ON: A description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain which physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

 ◦Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)

◦Chapter 17, “Abdomen” (pp. 370-415)

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

◦Chapter 3, “Abdominal Pain” (pp. 11-32)

◦Chapter 10, “Constipation” (pp. 110-117)

◦Chapter 12, “Diarrhea” (pp. 133-147)

Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis. ◦Chapter 7, “Admitting a Patient to the Hospital” (pp. 143–188)