SAOP Note: Hispanic female who presents to the clinic with an abdominal pain complaint

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.

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.

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

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

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

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

The skin is dry, warm, and intact,

No shortness of breath or cough.

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

Normal bowel sounds.

Abdominal pain and nausea noted.

Ears; nor hearing loss or pain.

No burning during urination odor or odd colors were reported.

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

No joint stiffness or joint pain was reported.

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

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

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

No mental issues were identified.

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

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

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.

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

No shortness of breath or cough.

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

 No masses, swelling, or color changes were noted.

No joint stiffness or joint pain

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

No mental issues were identified.

Ø  Complete blood count (CBC)

Ø  Comprehensive metabolic panel (CMP)

Ø  Thyroid-stimulating hormone (TSH)

Ø  Vitb12

Ø  Folate (vitb-9)

Ø  Lipid panel

CT scan

Colonscopy.

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.

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).