SOAP 3 GERD
SOAP 3 GERD
| Patient Initials: S. M. | Pt. Encounter Number:1 | |
| Date:01-20-2020 | Age: 78 | Sex: Male |
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Allergies: NKA Advanced Directives: NO |
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| SUBJECTIVE | ||
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CC: “STOMACH BURNING AND CHEST DISCOMFORT” |
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| HPI: PATIENT IS 78 YEARS OLD HISPANIC MALE, COMPLAINING IF STOMACH BURNING AND RETROSTERNAL DISCOMFORT THAT OCCURS WITHIN 1 HR AFTER EATING AND START 2 MONTH AGO. THE SYMPTOMS ARE RELATED WITH SOME FOODS LIKE COFFE, CHOCOLATTE AND SPICY FOODS. THE CHEST DISCOMFORT IS RELIVED WITH CHEWBABLE TUMS. | ||
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Current Medications: ENALAPRIL 10 MG PO BID HTN, METFORMIN ER 1000MG PO AT NIGHT DM2, ASA 81 MG PO DAILY HEART, PLAVIX 75MG PO DAILY ANTICOAGULANT, ATORVASTATIN 40 MG PO DAILY HLD, METOPROLOL 50 MG PO BID HTN |
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PMH: HTN, HLD, DM2 (2006), CAD (2007 ), CORONARY ARTERY BYPASS(2015) Medication Intolerances: NONE Allergies: NKA Chronic Illnesses/Major traumas: DM2, CAD Screening Hx/Immunizations Hx: CURRENT AND COMPLETE, LAST COLONOSCOPY 2015, LAST EYE EXAMINATION 2019 NORMAL Hospitalizations/Surgeries: CORONARY ARTERY BYPASS(2015) JACKSON MAIN HOSPITAL |
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Family History: MOTHER DEAD 53YO, MI FATHER DEAD 78YO, ESRD R/T DM2 COMPLICATIONS MATERNAL GRAND: NO RECALL GRANDMOTHER: DIABETES PATERNAL GRAND FATHER : NO RECALL GRANDMOTHER :DIABETES SIBBLING: 3 DAUGHTERS HEALTHY GRANDCHILDRENS: 3 HEALTHY |
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| Social History: married, former smoker, no alcohol, no illicit drugs, retired, low income with social security supplementary, live with her wife 68 years old in 1-bedroom apt section 8, has Medicaid and Medicare | ||
| ROS | ||
| General: denies fatigue, denies fever, denies headache, lethargy, weakness, night sweats, fainting spells, unconscious, denies weight loss, weight gain, denies dizziness, denies insomnia SOAP 3 GERD |
Cardiovascular: report chest discomfort, denies palpitation, denies edema, denies blue fingers/toes, heart murmur. report CAD 2007 and coronary artery bypass 2015 SOAP 3 GERD
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Skin: denies rash, itching, denies skin lesion, denies change in skin color, |
Respiratory: denies SOB, night sweats, prolonged cough, wheezing, sputum production, denies prior respiratory infections, oxygen at home, denies coughing blood
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Eyes: report cataract right eye, denies eye pain, drainage, discharge, denies vision changes, loss, blurred vision, dryness, denies eye irritation, last eye exam 2019 normal. |
Gastrointestinal: report stomach burning after eating denies nausea late afternoon. denies abdominal pain, blood in stools, denies vomit, bloating, denies diarrhea, constipation.
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Ears: denies earache, discharge, drainage, denies hearing loss or change, denies ringing |
Genitourinary/Gynecological Denies blood in urine, denies CVA tenderness. Denies incontinence,
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SOAP NOTE
| Nose/Mouth/Throat Denies nasal congestion, change in smelling, denies change in taste sore throat, denies difficult swallow, denies teeth loss, denies oral mucosa lesion | Musculoskeletal: denies fatigue, denies pain, swelling, stiffness, decreased joint motion, broken bone, serious sprains, arthritis, gout. | |
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Breast: denies pain, denies masses, lumps, nipple discharge. |
Neurological: denies headache, seizures, loss of consciousness, fainting, weakness, loss of muscle size, muscle spasm, tremors, denies involuntary movements, incoordination, numbness, denies feeling of” pins and needles/tingles “
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Heme/Lymph/Endo denies anemia, easy bruising/bleeding, denies past transfusions, denies increased thirst, denies excessive sweating, denies heat/cold intolerance, denies increased appetite. |
Psychiatric: denies sadness, depression, denies anxiety, change in mood, denies tension, denies hallucinations, denies suicide ideation, memory problems, sleep problems, denies past treatment with psychiatrist, denies change in attitudes towards family and friends
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| OBJECTIVE | ||
| Weight 148LBS BMI 24.63 | Temp 97.8 | BP 128/82 |
| Height 65 INCH | Pulse 78 | Resp 16 |
| PHYSICAL EXAMINATION | ||
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General Appearance: Gently 78 year old Hispanic male, alert and oriented to person time and place, well nourished , well groomed, only source of information , able to verbalized her needs , able to communicate without barriers , good behavior, adequate mood, no gait disturbances observed, in no noticeable distress during my interview . |
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Skin: intact, no skin lesion, no skin breakdown, no ulcers noted no discoloration, good turgor and normal coloration for her race |
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| HEENT: normocephalic, PERRLA, EOMs intact. Ear canal patent, no redness no discharge, normal amount of cerumen, tympanic membrane clear, pale gray color. Intact, cone of light present right at 5 o’clock, left at 7 o’clock, no TMJ dysfunction, Neck negative for masses, no goiter, no cervical adenopathy, no jugular vein distention | ||
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Cardiovascular S1 S2 present, no S3 no S4, PMI midclavicular line, no murmur noted at auscultation |
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Respiratory: anterior posterior lungs clear at auscultation, no adventitious sounds, expected tactile fremitus, resonant percussion no dullness no tympanic. Eupneic respiration. |
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Gastrointestinal Abdomen round, nontender non distended, BS normal active 4 abdominal quadrants, soft, no masses no organomegaly note at palpation. |
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Breast: deferred |
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Genitourinary: No CVA tenderness, no suprapubic tenderness. Genitalia: deferred |
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Musculoskeletal: No joint deformity, no bone deformity, no muscular atrophy noted, full ROM all synovial joints, full neck ROM spine |
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Neurological: Alert and Oriented x 3, sensation intact bilateral upper and lower distal to proximal extremities, speech clear. |
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PSYCHIATRIC: NO TICKS, NO BIZZARRE MOVEMENT, NO CRYING, NO DISHEVELED APPAREANCE ANSWER NEGATIVE TO: -DURING THE PAST MONTH, HAVE YOU FELT DOWN, DEPRESSED OR HOPELESS? AND DURING PAST MONTH, HAVE YOU FELT LITTLE INTEREST OR PLEASURE DOING THINGS? SOAP 3 GERD |
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| Lab Tests: NONE |
| Special Tests: NONE | ||||
| Diagnosis | ||||
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Primary Diagnosis–
· k21.9 – GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS Differential Diagnoses:
· PEPTID ULCER DISEASE ICD10: K27 · ACHALASIA ICD10: K22.0 · GASTRITIS ICD10: K29.70
PLAN : Labs:
Pharmacology Treatment: · CONTINUOUS WITH PREVIOUS MEDICATION PROFILE · OMEPRAZOLE 30 MG po bid FOR 8 WEEKS Non-Pharmacology Treatment: · DISCUSSED WITH THE PATIENT IN DETAIL THE BENEFITS, RISK AND SIDE EFFECTS OF PROTON PUMP INHIBITORS MEDICATION IN THE TREATMENT OF GERD · AVOID ALCOHOL AND SPICY, FATTY OR ACIDIC FOODS THAT TRIGGER HEARTBURN LIKE PEPPERMINT, CHOCOLATE, COFFE. · EAT SMALLER MEALS, AVOID EAT AFTER CLOSE TO BEDTIME, WEAR LOOSE FITTING CLOTHES · KEEP UPRIGHT POSITION FOR AT LEAST 30 MIN AFTER ,EALS Activity · ENCOURAGE SHORT WALKS AT LEAST 3 TIMES PER WEEKS, EARLY IN THE MORNING OR LATE IN THE AFTERNOON · KEEP WELL HYDRATED Referral: NO Follow Up · NEXT APPOINTMENT IN 4 WEEKS · PHONE CALL FOLLOW UP IN 2 WEEKS FOR SUICIDAL SCREENING · REFERED TO PSYCHOTHERAPY |
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References
Buttaro, T. M., Trybulski, J., Polgar, B.P. & Sandberg-Cook, J. (2015). Primary Care: A Collaborative
Practice. Elsevier Health Sciences Codina, M. L. (2018). Family Nurse Practitioner Certification: Fast Facts and Active Questions. Third Edition. New York: Springer Publishing Company Blunt, E. (2009). Family Nurse Practitioner: Nursing Review and Resource manual ( 4th ed., Vol 1).Silver Spring, MD: American Nurses Credentialing Center. SOAP 3 GERD |
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