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SOAP NOTE

 

Name: X.M. Date: 02/09/2022 Time: 
  Age:53 Sex: Female
SUBJECTIVE
CC:

A 53-year-old Hispanic female presents to the clinic with a complaint, “I’ve been experiencing abdominal discomfort over the past one week, and the pain has worsened over the past few days.

 

HPI:

The patient is a 53-year-old Hispanic female who presents to the clinic with an abdominal pain complaint. The patient has been experiencing abdominal pain/discomfort and nausea for the past week, which has worsened over the last few days. She rates the abdominal pain as a 6/10. Seven years ago, she had a C-section has a history of hypertension and anemia. She denied the existence of allergies to drugs, the environment, or any toxic habits.

 

Medications: Carvedilol 12.5 mg 1-tab PO daily.

 

 

Family History: Both parents are alive. The father has a history of gout and diabetes mellitus. The mother has a history of hypertension.

Social History

Both the parents are alive, and the patient does not engage in toxic habits.

 

 

ROS
General

 

The patient is 25-years old. No fever, chills,

Cardiovascular

 

Regular rhythms, no murmurs, no chest pain, edema, or other discomforts. Elevated blood pressure,

Skin

 

The skin is dry, warm, and intact,

Respiratory

 

No shortness of breath or cough.

 

Eyes

 

No blurred or double vision, no visual loss or yellowing of the sclerae.

Gastrointestinal

 

Normal bowel sounds.

Abdominal pain and nausea noted.

Ears

 

Ears; nor hearing loss or pain.

Genitourinary/Gynecological

No burning during urination odor or odd colors were reported.

 

Nose/Mouth/Throat

 

Nose; no runny nose, sneezing, or congestion. Throat; no sore throat reported.

 

Musculoskeletal

 

No joint stiffness or joint pain was reported.

Breast

 

No masses, lumps, or skin color changes were noted. The breasts were symmetrical.

Neurological

There are no headaches, tingling in the hands or legs, dizziness, paralysis, slurring of speech, or ataxia. No changes in bladder and bowel movements.

Heme/Lymph/Endo

 

No reports of sweating, heat intolerance, polyuria, or polydipsia. No enlarged lymph nodes. No bruising, anemia, or bleeding.

 

Psychiatric

 

No mental issues were identified.

OBJECTIVE

 

Weight   lb    BMI  Temp oral BP
Height 65 inches Pulse 88 Resp 28
General Appearance

The patient is female, 5.4 ft. She is appropriately dress and appears hear age.

 

Skin

No bruises or rashes were noted. The skin is dry, warm, and intact.

 

HEENT

 

No blurred or double vision, no visual loss or yellowing of the sclerae. Ears; nor hearing loss or pain. Nose; no runny nose, sneezing, or congestion. Throat; no sore throat observed.

 

Cardiovascular

Regular rhythms, no murmurs, no chest pain, edema, or other discomforts. Elevated blood pressure,

Respiratory

No shortness of breath or cough.

Gastrointestinal

 

Normal bowel sounds, abdominal pain, and nausea were noted. No masses or abnormal bowel movements.

Breast

 No masses, swelling, or color changes were noted.

Musculoskeletal

No joint stiffness or joint pain

 

Neurological

There are no headaches, tingling in the hands or legs, dizziness, paralysis, slurring of speech, or ataxia. No changes in bladder and bowel movements.

Psychiatric

No mental issues were identified.

 

 

Lab Tests

Ø  Complete blood count (CBC)

Ø  Comprehensive metabolic panel (CMP)

Ø  Thyroid-stimulating hormone (TSH)

Ø  Vitb12

Ø  Folate (vitb-9)

Ø  Lipid panel

Special Tests

CT scan

Colonscopy.

Diagnosis
Differential Diagnoses

Diverticulitis – The diverticula’s infection or inflammation and is characterized by abdominal pain, nausea, and or vomiting. The patient, in this case, had two of the symptoms (Strate & Morris, 2019).

Irritable bowel syndrome (IBS) – characterized primarily by abdominal pain. Other symptoms include nausea, cramping, and bloating (Black et al., 2020).

 

Gastroesophageal reflux disease (GERD) is a chronic condition characterized by acid reflux into the esophagus. While acid reflux is an occasional occurrence in most people, it can be a chronic condition that results in damage of the esophagus leading to abdominal pain. Other symptoms include vomiting, nausea, and bad breaths (Clarrett & Hachem, 2018).

 

Diagnosis

 

Diverticulitis; The diagnosis for this patient is diverticulitis, which is an inflammation of the diverticula that is characterized by nausea, vomiting, and abdominal pain. Several risk factors increase the chances of the patient suffering from this condition. This includes advancement in age; as one advance in age, the risk increase. The patient is 53 years old, which increases her risk of suffering from the condition. The patient was also taking Carvedilol 12.5 mg, which is used to control hypertension and has been linked to an increased risk of developing diverticulitis. Diverticulitis is the most appropriate diagnosis based on the symptoms and the risk factors.

 

Plan/Therapeutics
Plan:

Ø  Treatment will include antibiotics to manage infections.

Ø  The patient should receive pain relievers such as paracetamol to manage the abdominal pain.

Ø  The patient should adopt a liquid diet for a few days until the bowel heals, after which solid foods will be introduced. High-fiber diets are always recommended to facilitate smooth bowel movements and prevent unnecessary complications that can limit the healing.

Ø  The patient should get bed rest which can facilitate faster healing (Peery, 2021).

Evaluation of patient encounter
The patient was a 53-year-old Hispanic female. She presented with abdominal pain and nausea complaints. She has hypertension and is currently taking medication Carvedilol 12.5 mg 1-tab PO daily. She has no known allergies. The examination included a review of the systems and laboratory tests, including CBC, CMP, TSH, Vitb12, Folate, and Lipid panel. The patient was diagnosed with diverticulitis. Antibiotic therapy was initiated.

 

 

References

Black, C. J., Drossman, D. A., Talley, N. J., Ruddy, J., & Ford, A. C. (2020). Functional gastrointestinal disorders: advances in understanding and management. The Lancet396(10263), 1664-1674. https://www.sciencedirect.com/science/article/abs/pii/S0140673620321152

Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal reflux disease (GERD). Missouri medicine115(3), 214. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140167/

Peery, A. F. (2021). Management of colonic diverticulitis. bmj372. https://www.bmj.com/content/372/bmj.n72.short

Strate, L. L., & Morris, A. M. (2019). Epidemiology, pathophysiology, and treatment of diverticulitis. Gastroenterology156(5), 1282-1298. https://www.sciencedirect.com/science/article/abs/pii/S0016508519300460

 

 

 

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