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Case Study
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Discuss The Subjective Information, Objective, Assessment And Plan (Case Study Sample)


Instructions: This is a case study as if you've seen the patient and talking about this particular patient. Discuss the Subjective information, objective, assessment and plan. Include this information (but i need paragraph form with discussion on the above topic):: rescriptions MetroNIDAZOLE 500 MG Oral Tablet Ciprofloxacin HCl (Cipro) 500 MG Oral Tablet Take 1 tablet (500 mg) by mouth 3 times per day for 10 days Take 1 tablet (500 mg) by mouth every 12 hours for 10 days 03/04/18 03/04/18 - - - - Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding - EScript: 03/04/18 Prescriber: Igwebuike Onyekaba MD Refills: 0 Quantity: 30 EScript: 03/04/18 Prescriber: Igwebuike Onyekaba MD Refills: 0 Quantity: 20 Social history Print Smoking status Record No smoking status recorded Gender identity Record No gender identity recorded Sexual orientation Record No sexual orientation recorded Past medical history Record Print No past medical history recorded Record and review allergies in the Allergies section. Note subjective Edit Patient has been previously diagnosed with diverticulitis in 2013. She has not had a flare up since then. When she feels as though she is having a flare up then she will drink liquids to reduce the pain. For the past 7 days she has been having LLQ pain that radiates medially. The pain flares after she eats then will resolve a few hours later. However, early Friday morning she had emesis after being in pain from eating on Saturday night. When the pain is present it is "crampy" and she states that it feels as though she needs to use the bathroom which is then accompanied with diarrhea. Current pain level is (0/10). Review of Systems:. Denies weight loss, night sweats, fatigue/malaise/lethargy, sleeping pattern changes, changes in appetite or fever and chills.. EYES: Denies visual changes, headache, eye pain, double vision, blind spots, or floaters.. ENT: Denies runny nose, nose bleeds, sinus pain, ear pain, ringing in the ears, gums bleeding, tooth ache, sore throat, or difficulty swallowing.. Cardiovascular: Denies Chest pain, SOB, exercise intolerance, PND, orthopnea, palpatations, faintness, LOC, or,claudication.. Respiratory: Denies cough, sputum, wheezing, or hemoptysis.. Gastrointestinal: (+) lower left abd pain, (+) positive diarrhea after eating, (+) nausea and vomiting x7days Genitourinary: Denies incontinence, dysuria, hematuria, nocturia, polyuria, hesitancy, or decreased force of stream.. Musculoskeletal: Denies stiffness, joint swelling, decrease in ROM, crepitus, or functional deficit.. Skin: Denies pruritus, rashes, lesions, lumps or bumps.. Neurological: Denies seizures ,Dizziness, fainting, paraesthesia, numbness, limb weakness, poor balance, speech problems or problems with memory.. Psychiatric: Denies depression, sleep patterns, anxiety, difficulty concentrating, paranoia, lack of energy, changes in personality, or sexual dysfunction.. Endocrine: Denies weight loss, change in appetite, thinning hair, dry skin, polydipsia, polyuria, polyphagia, sweating, trouble concentrating, changes in sexual arousal, or lack of stamina/energy.. Hematologic/lymphatic: Denies unusual bleeding, bruising, anemia, lumps/knots in axilla or groin.. objective Edit General: Alert and oriented X 3 and in no cardiorespiratory distress.. Head: Normocephalic, no lesions. Eyes: PERRLA, EOM's full, conjunctivae clear, fundi grossly normal. . Ears: EAC's clear, TM's normal. . Throat: Clear, no exudates, no lesions.. Nose: Mucosa normal, no obstruction. Neck: Supple, no masses, no thyromegaly, no bruits. Chest: Lungs clear, no rales, no rhonchi, no wheezes.. Heart: RR, no murmurs, no rubs, no gallops. Abdomen: Soft, (+) tenderness in LLQ, no masses, BS normal. (+) grimacing on palpation GU: Normal, no lesions, no discharge, no hernias noted.. Back: Normal curvature, no tenderness. Extremities: no deformities, no edema, no erythema. Neuro: Physiological, no localizing findings. Skin: Normal, no rashes, no lesions noted. Murphy sign = negative assessment Record No assessment recorded. Diagnoses attached to this encounter: (K57.92) Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding plan Edit Print visit summary Increase fiber in diet, may supplement with otc fiber supplements. BRAT diet, advance as tolerated. Return to clinic immediately or go to ER if fever, intractable vomiting, or blood in stool. Take medications as prescribed.. RTC for follow up of labs in 2 weeks. Counseling: On bland diet and increasing water intake Electronic Rx sent. Medications attached to this encounter: Ciprofloxacin HCl (Cipro) 500 MG Oral Tablet Sig: Take 1 tablet (500 mg) by mouth every 12 hours for 10 days MetroNIDAZOLE 500 MG Oral Tablet Sig: Take 1 tablet (500 mg) by mouth 3 times per day for 10 days
Focus: Diverticulitis
Structure: Sections to be included: S - subjective - Discuss patient presentation, family history, surgery history (none), social history PLEASE MAKE UP THE INFORMATION AS IF YOU'VE REALLY SEEN THIS PATIENT IN CLINIC O-objective - discuss the examination that you would do for the patient here. A- assessment - this is diverticulitis - please give pathophysiology of disease here P - plan - discuss treatment plans and approaches. Starting with what we would normally do and extreme treatment
Important notes: Please make up the subjective information - ex. pt walks into clinic presents with abd pain for 3x. etc etc. DIRECTIONS FROM INSTRUCTOR: Each student will discuss an unusual diagnosis, or a complex case that required in-depth evaluation on their part. The case should be documented in essay form utilizing references for the diagnosis, differential diagnoses (at least 3), and the treatment plan. The essay and references should be written in APA format with correct spelling and grammar. Each reference should reflect current evidence based practice, with evidence being no older than five years old. Up To Date may be used as one of the references, but should not be the sole reference.
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Case study: Diverticulitis
Case study: Diverticulitis
Subjective information
Patient presentation
The 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 difficulties; 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 history
There was no available information concerning the patient’s family history. There was neither access to the family genogram nor the family history 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 history
The 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.
Since 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 (sigmoidoscopes/ 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 diverticulitis
The 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...
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