Discussion week 7

Abdominal Pain
Author’s Name
Institution

Episodic/Focused SOAP Note
Patient Information:
12 years, F, A
S.
CC (Chief complaint) – Abdominal pain
HPI
Location: Right lower quadrant
Onset: 3 evenings
Character: Abdominal pain with malaise
Associated signs and symptoms: Nausea, vomiting, low appetite, fever
Timing: The pain has been progressive since onset
Relieving factors: Taking acetaminophen and ipobrufen and lots of water.
Severity: 7/10 pain scale
Current Medications: The patient has had acetaminophen and ipobrufen.
PMHx: Malaria three months ago treated using Chloroquine after a trip to Nigeria
Soc Hx: The patient likes to spend time with friends and partying. She also enjoys travelling and accompanies the father to some of his international trips. The patient stays with both parents and claims to have a hygienic environment at home. Her mother is a quality assurance officer at a hotel and is keen about hygiene. She is under no exposure to drugs whatsoever.Fam Hx: The patient’s family has a history of sensitive gut on her mother’s side; a reason why the mother is very keen on hygiene.
ROS:
GENERAL: Fever present. Feelings of unease and fatigue
HEENT: Eyes: No blurred vision, double vision or visual loss. Ears, Nose, Throat: no hearing loss, no sore throat or running nose.
SKIN: The patient has a skin tan. The tan is uniform.
CARDIOVASCULAR: The patient does not experience any chest pain or discomfort.
RESPIRATORY: The patient has no respiratory infection and history of such.

GASTROINTESTINAL: Nausea, vomiting and loss of appetite.
GENITOURINARY: The patient does not experience a burning sensation during urination.
NEUROLOGICAL: The patient experiences dizziness and fatigue.
MUSCULOSKELETAL: The patient has no back pain, muscle pain, joint pain or stiffness.
HEMATOLOGIC: The patient has mild anemia.
PSYCHIATRIC: The patient has not been anxious or depressed in the past but now experiences unease and general discomfort.
LYMPHATICS: The patient has no enlarged glands.
ENDOCRINOLOGIC: The patient is not experiencing any heat intolerance or sweating but has a fever.
ALLERGIES: The patient has a mildly sensitive gut but is not allergic to specific foods and medications.
O.
Physical exam: After examining the patient’s abdomen, the skin color appears the same as other body parts. However, the lower quadrant, where the patient indicated as the source of pain, appeared dull. No lesions or scars were visible. The patient appeared slightly bloated and the abdomen protruding. The patient’s face indicated pain upon palpitation.
Diagnostic results: The physical exam and blood tests leaned towards appendicitis. The blood test showed a significant increment in the production of the white blood cells (Craig & Infante, 2011). The x-ray conducted indicated an inflammation too.
A.
Differential Diagnoses
Pyelonephritis: The patient may be suffering from an infection of the upper urinary tract (Johnson & Russo, 2018). This disease of the kidney causes the symptoms depicted by the patient. However, she had no painful urination and the blood test confirmed the absence of the infection.
Diverticulitis: the patient may be suffering from Diverticulitis since she experiences nausea and vomiting alongside the severe abdominal pain. She has also lost appetite and experiences fever. This condition is, however, less probable since it is caused by low-fiber diets. Her mother is keen about diet and hygiene.
Food Poisoning: since she likes to party and spend time with friends, she may be having food poisoning. The nausea, vomiting, fever, and abdominal pain are signs of food poisoning (Mayo Clinic, 2017). The patient, however, has no incidences of diarrhea. The extent of the symptoms may be too prolonged to be food poisoning.
Inflammatory Bowel Disease: The patient has symptoms that indicate the probability of this condition. The absence of diarrhea, bloody stool, or unintended weight loss may mean that this condition is not the cause of the symptoms.
Mononucleosis: the symptoms of this disease seem in line with what the patient has been experiencing. However the sore throat is absent as are any symptoms of respiratory infections. The abdominal pain might be from a different condition. However, the absence of any throat-related symptoms overrules the rest of the symptoms.

References
Craig, M., & Infante, S. (2011). Abdominal mysteries: Pain, peritonitis, pancreatitis, pseudocyst. Continuing Nursing Education, 38(2), 173-185.
Johnson, J. R., & Russo, T. A. (2018). Acute pyelonephritis in adults. The New England Journal of Medicine.
Mayo Clinic. (2017, July 15). Food poisoning – Symptoms and causes. Retrieved from https://www.mayoclinic.org/diseases-conditions/food-poisoning/symptoms-causes/syc-20356230