Client Assessment
Client History
The initial diagnosis was diverticulitis. However, a CT scan was recommended as a precaution measure. The client’s medical history led to a need for a CT scan. The client reports historical stomach pains and diarrhea. Also, abdominal pains are said to have occurred for several days before the visit. The client has not taken any medication associated with the conditions because they did not know the right medication to take. Also, the abdominal pains have been worsening each day, calling for the client to visit the health facility. Moreover, the client has not been able to eat with frequent cases of nausea.
The only reported history of medical concern is a previous diagnosis of diabetes. For four years, the client has been under medication. The history shows that the client’s father has a history of DMT2 and NTH. The client’s mother has a history of NTH while the client has no history of colon cancer. The client is also married and is a father of two girls and one boy.
Differential Diagnosis
The claim from the client that abdominal pains are a cause for discomfort, several diagnoses are made. First, a CT scan is done to check for cases of colon cancer and pancreas cancer. Other possible causes, such as kidney problems, are considered. The client does not use tobacco and alcohol, and thus, they are excluded as possible causes. The doctor takes several laboratory tests to confirm any abnormalities in the abdomen, but no positive result is obtained. Also, the client has not had any other significant medical issues apart from the diabetes case reported. Since other tests are normal, the client is involved in discussing the possible medications for diverticulitis.
Subjective
The chief complaint from the patient is abdominal pain. The client does not know the cause for the pain, so they do not mention any problem initially.
The history of present illness involves a middle-aged gentleman who complains of abdominal pains. According to the client, the pains have been felt for the last three days. The pain is located in the stomach area and has not ceased since it started. The client reports that the pain is alleviated by taking food, and thus, he has not eaten for the three days. According to the client, the pain can be rated at 5/10, although the pain has gone to 9/10.
The subjective history of the patient involves an earlier diagnosis of diabetes. Also, the client’s parents have a history of DMT2 and NTH. The client does not mention any other significant historical concern.
Objective
Laboratory tests are done to check for abnormalities in the abdomen. A CT scan is also done (Pearce, Ferguson, George & Langford, 2016). The client tests negative for other possible causes of abdominal pain, leaving diverticulitis as the likely cause.
The subjective information provided seems to provide more support for the assessment. However, the impact of the objective information cannot be overlooked since crucial conclusions rely on objective information.
The information provided in the note is essential for the care plan that will be contacted after the assessment. The subjective part of the note includes historical information to assess any relationship between the client’s current condition and their medical background. Moreover, subjective information is not measurable and is used to provide the required conclusions. The objective part involves the assessment of quantifiable observations.
References
Pearce, P. F., Ferguson, L. A., George, G. S., & Langford, C. A. (2016). The essential SOAP note in an EHR age. The Nurse Practitioner, 41(2), 29-36.
Sando, K. R., Skoy, E., Bradley, C., Frenzel, J., Kirwin, J., & Urteaga, E. (2017). Assessment of SOAP note evaluation tools in colleges and schools of pharmacy. Currents in Pharmacy Teaching and Learning, 9(4), 576-584.
Sherman, J. J., & Johnson, C. D. (2019). Assessment of pharmacy students’ patient care skills using case scenarios with a SOAP note grading rubric and standardized patient feedback. Currents in Pharmacy Teaching and Learning, 11(5), 513-521.