Discuss The Subjective Information, Objective, Assessment And Plan - 825 Words

Discuss The Subjective Information, Objective, Assessment And Plan (Case Study Sample) Content: Case study: DiverticulitisNameCourseInstitutionCase study: DiverticulitisSubjective informationPatient presentationThe patient was a female, an American of African-American origin aged 40 years. She exhibited symptoms diagnosed as diverticulitis of large intestine (colon). The specific part was unidentified and she showed no perforations as well as no abscess with no bleeding. The patient had no past medical history concerning any allergies. In 2013 she had been diagnosed with diverticulitis. Since that time, she had not been diagnosed with any other instance of a flare. During the previous 7 days, she had been exhibiting LLQ pain radiating medially. The pain increases when she eats then resolves some few hours later. However, early on Friday morning, she experienced emesis after doing the Saturday night. During the pain, she feels crampy as if she would use the washroom accompanied with diarrhea. Her pain levels at the moment was 0/10. She denied having any eye diffi culties; she had no pain in the eyes, headaches, blind spots and her double vision was normal. The patient claimed to have no ENT problems; she had no running nose, nose bleedings, ear pain, bleeding gums, sore throat, as well as swallowing problems. The client denied having respiratory problems; she said that she had no chest pains, coughs. She stated that she did not experience cardiovascular problems as well as genitourinary problems. Moreover, the patient denied having any musculoskeletal, neurological, psychiatric, endocrine, hematologic, head, neck, throat, and heart difficulties. Her skin was normal and her back indicated normal shape without tenderness. However, the patient stated that she experienced gastrointestinal complications; she had pain in her lower abdomen, diarrhea after eating, nausea and vomiting for seven days.Family historyThere was no available information concerning the patients family history. There was neither access to the family genogram nor the family h istory concerning specific health concerns such as diabetes, coronary problems, or high blood pressure. If she felt any pain, she would drink liquids to lower the pain.Social historyThe patient had no any history of smoking. Her gender identity or sexual orientation had not been recorded previously. Moreover, she had no any past records concerning the use of any drug. The patient lived with her three children and her husband divorced her in 2010.ObjectiveSince the symptoms exhibited by the patient are limited, and they match with other diseases, it is important to have a specific test for determining the identity of the disease. There are a variety of tests that can be used to identify diverticulitis. However, in this situation, the Barium X-rays also called barium enemas is appropriate because it gives a clear visualization of the colon. Alternatively, the use of flexible tubes passed via the rectum can be used to test diverticulitis by visualizing the colon. The short/long tube (s igmoidoscopes/ colonoscopies) may be used so that one can distinguish the diverticulitis from the other diseases with similar symptoms. Moreover, for patients suspected to have diverticulitis, the caregiver can opt to use ultrasound combined with CT (Computerized Tomography) for the examination of the abdomen so that the sources of the inflammation can be identified (Marks, 2018).Assessment of diverticulitisPathologyThe term diverticula refer to the small sacs/bulges that form at the inner side of the colon (large intestine). Diverticular disease refers to the symptoms such as abdominal pains that occur as a result of the presence of diverticula. However, diverticulitis is an infection that occurs when the bacteria invade the diverticula and alleviate the symptoms (Marcin Persons, 2017). The bacterial infection leads to severe symptoms such as an abscess in the intestines. Apart from the abdominal pains, the bacterial infections lead to further severe complications such as diarrhea , constipation as well as bleeding of the colon (NHS, 2018).Diverticula is believed to be caused due to the aging of the colon. The inner wall of the colon becomes large and subjected to high pressure. The inconsistency development of the strength to pass out the feces as we...