History of Present Illness (HPI)

Soap Note
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History of Present Illness (HPI)
Mrs. Park reports that she has been having abdominal pains, which has been gradually worse or almost a week. She notes that it generally affects her entire abdomen. However, the pain is more severe in the lower left quadrant of the stomach. She reports that she has been having abdominal pain for five days. Mrs. Park says that she has been in abdominal discomfort for five days with severity on her lower abdomen. She experienced diarrhea once and has not had any bowel movement since then. Mrs. Park denies any nausea, vomiting, blood or mucous in stool, rectal bleeding, or fever. She also relates that she has not had any episodes of vaginal bleeding or discharge. She denies any history of inflammatory disease of GERD as well as gastrointestinal disorders. However, her appetite has become impoverished over the last couple of days. Initially, she reports normal brown soft stool daily. Mrs. Park relates that the pain intensifies when she moves around or eats any food. However, she notes that not eating reduces her pain intensity; thus, she takes warm tea and little warm water. Mrs. Park reports that she does not use any medication for the pain. Mrs. Park also rates the pain at 6/10 and describes it as constant, dull, and cramped. Due to warm tea and water consumption only, she has experienced a sharp decrease in her energy levels and finds herself getting tired more often. Mrs. Park's perception of cause and effects of experienced symptoms is cholecystectomy and diabetes type 2.
PMH:
* Hypertension diagnosed at age 54
* Cholecystectomy was done at age 42
* C-section did at age 40
Hospitalization:
* Cholecystectomy done at age 42
* C-section did at age 40
Family History:
* Mother deceased age 88 had hypertension and diabetes type 2
* Father deceased, age 82, had hypertension and hypercholesterolemia
* She has a brother, age 81, with a history of hypertension
* Her second brother, age 80 years, has hypertension, hypercholesterolemia, and prostate cancer
* She has one son, age 48, who is healthy
* She has a daughter age 46 years who are healthy
* Maternal grandparents' family had a history of coronary artery disease and diabetes mellitus type 2
Differential diagnosis
Constipation
Constipation is characterized by the inability to pass stool that lasts for a week or more days. Mrs. Park had diarrhea once a week (Vriesman et al., 2020). Being an older adult woman, eating foods that are low in fiber predisposes her to constipation.
Diverticu...