The document outlines instructions for creating a SOAP note concerning a 50-year-old male with gastrointestinal pain. It emphasizes the need to collect a detailed health history, conduct appropriate physical exams and diagnostic tests, and formulate a differential diagnosis of at least five potential conditions. Additionally, the document specifies that the notes should adhere strictly to the SOAP format and references several educational resources to support the analysis.

1. Make a SOAP Note Not a narrative essay: Assessing the
Abdomen
Note:
Your Discussion post should be in the SOAP Note format,
rather than the traditional narrative style Discussion posting
format. Refer to the Comprehensive SOAP Template in the
attachments below for guidance.
CASE:
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.
To prepare:
With regard to the case study:
·
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

2. possible conditions that may be considered in a differential
diagnosis for the patient.
Address all these in the SOAP Note not an Narrative Essay
(Follow the SOAP Note Template on the attachment):
1.
A description of the health history you would need to collect
from the patient in the case study to which you were assigned.
2.
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.
3.
A description of the health history you would need to collect
from the patient in the case study 2.
4.
Explain what physical exams and diagnostic tests would be
appropriate and how the results would be used to make a
diagnosis.
5.
List
five
different possible conditions for the patient's differential
diagnosis, and justify why you selected each.
REMINDER:
Please make a SOAP NOTE for this case. Make your own
patient’s data, applicable health history, review of systems,
P.E., labs, differential diagnosis, final diagnosis etc.
Incorporate the data from the case in the SOAP note that you

3. will do… This is not a narrative essay ok…. I need SOAP note
(Nurse Practitioner/RN/MD makes SOAP note)… Be guided
with the SOAP Note in the templates/exemplar… Don’t copy
paste. Formulate your own… Don’t forget to cite the Five
different possible conditions (Differential diagnosis) and have
Reference lists too.
Resources:
·
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.
o
Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)
This chapter describes the experience of pain and its causes.
The authors also describe the process of pain assessment.
o
Chapter 17, “Abdomen” (pp. 370-415)
In this chapter, the authors summarize the anatomy and
physiology of the abdomen. The authors also explain how to
conduct an assessment on the abdomen.
·
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.
o

4. Chapter 3, “Abdominal Pain” (pp. 11-32)
This chapter outlines how to collect a focused history on
abdominal pain. This is followed by what to look for in a
physical examination in order to make an accurate diagnosis.
o
Chapter 10, “Constipation” (pp. 110-117)
The focus of this chapter is on identifying the causes of
constipation through taking a focused history, conducting
physical examinations, and performing laboratory tests.
o
Chapter 12, “Diarrhea” (pp. 133-147)
In this chapter, the authors focus on diagnosing the cause of
diarrhea. The chapter includes questions to ask patients about
the condition, things to look for in a physical exam, and
suggested laboratory or diagnostic studies to perform.
o
Chapter 29, “Rectal Pain, Itching, and Bleeding” (pp. 344-356)
This chapter focuses on how to diagnose rectal bleeding and
pain. It includes a table containing possible diagnoses, the
accompanying physical signs, and suggested diagnostic studies.
·
Sullivan, D. D. (2012).
Guide to clinical documentation
(2nd ed.). Philadelphia, PA: F. A. Davis.
o

5. Chapter 7, "Admitting a Patient to the Hospital" (pp. 143–188)
Note:
Download this Adult Examination Checklist and Abdomen
Physical Exam Summary to use during your practice abdominal
examination.
·
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011).
Adult examination checklist: Guide for abdominal assessment
. In
Mosby's guide to physical examination
(7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Abdominal
Assessment was published as a companion to
Seidel's guide to physical examination
(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright
Elsevier (2015). From https://evolve.elsevier.com/
·
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011).
Physical exam summary: Abdomen
. In
Mosby's guide to physical examination
(7th ed.). St. Louis, MO: Elsevier Mosby.
This Abdomen Physical Exam Summary was published as a
companion to
Seidel's guide to physical examination
(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright
Elsevier (2015). From https://evolve.elsevier.com/
·
Craig, M., & Infante, S. (2011). Abdominal mysteries: Pain,

6. peritonitis, pancreatitis.
Nephrology Nursing Journal
,
38
(2), 173–186.
Retrieved from the Walden Library databases.
This article explains various types of abdominal pain. The
authors detail the etiologies, symptoms, and treatment for the
abdominal pain described.
·
Mills, A. M., & Chen, E. H. (2011). Abdominal pain in special
populations.
Emergency Medicine Reports
,
32
(7), 81–91.
Retrieved from the Walden Library databases.
The authors of this article explore the characteristics and
diagnoses associated with abdominal pain in patients with
special conditions. The article also provides recommendations
for emergency department staff when encountering abdominal
pain.
·
University of Virginia. (n.d.).
Introduction to radiology: An online interactive tutorial
. Retrieved from
http://www.med-ed.virginia.edu/courses/rad/index.html

7. This website provides an introduction to radiology and imaging.
For this week, focus on gastrointestinal radiology.
Media
Online media for
Seidel's Guide to Physical Examination
It is highly recommended that you access and view the
resources included with the course text,
Seidel's Guide to Physical Examination
. Focus on the videos and animations in Chapters 7, and 17 that
relate to the assessment of the abdomen and gastrointestinal
system. Refer to Week 4 for access instructions on
https://evolve.elsevier.com/
.
Optional Resources
·
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009).
DeGowin’s diagnostic examination
(9th ed.). New York, NY: McGraw Hill Medical.
o
Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid”
(pp. 445–527)
This chapter explores the health assessment processes for the
abdomen, perineum, anus, and rectosigmoid. This chapter also
examines the symptoms of many conditions in these areas.
o
Chapter 10, “The Urinary System” (pp. 528–540)
In this chapter, the authors provide an overview of the

8. physiology of the urinary system. The chapter also lists
symptoms and conditions of the urinary system.