Soap Note Assigment
Patient information to complete the soap note. please see attachment
39-year-old Male with epigastric pain
Chief Compliant: “I’ve been having this abdominal pain, and it just seems like it won’t go away. It started probably a year ago. It used to happen a few times a week, now it hurts every day.
History of Present Illness: Mr. Rodriguez is a 39-year-old male that recently immigrated to the United States from Dominican Republic. He complains of epigastric pain that began approximately one year ago. He describes the pain as burning and occurring daily. He states that the pain sometimes worsens with eating and sometimes it improves. He states that spicy foods make the pain worsen. He admits to weekly NSAID usage and drinking 3-4 alcoholic beverages a week. He quit smoking 6 months ago. He drinks an herbal tea but does not experience any relief or change in the symptoms. He denies any fever, chills, nausea, hematemesis, hematochezia, or melena.
PMH/Medical/Surgical History: No history of gastrointestinal problems in the past. No history of surgery. No known drug allergies.
Medications: Takes ibuprofen almost daily for aches and pains associated with working. Drinks herbal tea meant to improve GI symptoms.
Significant Family History: Patient states family history of heart disease. Father had hypertension and his mother had diabetes.
Social History: Patient denies smoking. Patient states that he quit smoking 6 months ago. Patient states that he drinks 3-4 beers weekly. No illicit drugs.
Review of Symptoms:
GENERAL: 39-year-old Spanish speaking patient. Language interpreter present. Patient is alert and oriented. Afebrile. Patient denies recent, unexplained weight loss, fever, chills, weakness or fatigue.
HEENT: Denies headache, change in vision, nose, or ear problems. Denies sore throat.
SKIN: No change in skin, hair or nails.
CARDIOVASCULAR: Regular heart rate and rhythm. S1, S2, no murmurs, rubs, or gallops.
RESPIRATORY: clear to auscultation.
GASTROINTESTINAL: Soft, flat, non-distended. Normoactive bowel sounds heard in four quadrants. Soft, non-distended, with minimal epigastric tenderness on deep palpation without rebound tenderness or guarding, no hepatosplenomegaly, and no hernia or masses.
GENITOURINARY: Denies problems with urination.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Alert & oriented x3. Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. Denies history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety. Patient does express concern about paying for medications and follow up visits due to lack of insurance.
ENDOCRINOLOGIC: Denies sweating, cold or heat intolerance. Denies polyuria or polydipsia..
Objective Data:
Temperature:98.5 Fahrenheit
Heart rate:78 beats/minute, regular
Respiratory rate:16 breaths/minute
Blood pressure:133/82 mmHg
Body Mass Index:24.8 kg/m2- This BMI is within normal range according to the National Heart, Lung, and Blood Institute (2017).
Physical Assessment Findings: Patient is alert, oriented and is cooperative.
HEENT: PERRLA, no nystagmus noted. Tympanic membranes are intact. External auditory canals are normal. Oral pharynx is normal without erythema or exudate. Tongue and gums are normal.
Lymph Nodes: Non-palpable
Carotids: equal bilaterally 2+
Lungs: clear to auscultation
Heart: Regular rate and rhythm normal S1 and S2.
Abdomen: soft, non-tender, non-distended, no masses.
Genital/Pelvic: unremarkable
Extremities/Pulses: normal pulse bilaterally
Neurologic: A&Ox3, cranial nerves intact
Laboratory and Diagnostic Testing:
Fecal Occult Blood Testing: negative
Heliobacter Pylori (H. pylori) serology test: Positive
CBC with differential to test for other conditions such as anemia or pancreatitis.
Upper GI endoscopy: can help to check for damage to the lining of the stomach and to rule out malignancies (National Institutes of Health [NIH], 2017)
Upper GI Series: Commonly used in the past to diagnose peptic ulcers however this test can miss smaller ulcers and does not allow for direct treatment of the ulcer (American College of Gastroenterology, 2017).
Chest x-ray: This test is not normally used due more effective imaging for GI issues, but could be helpful to rule out other diagnoses such as a hiatal hernia or other abnormal anatomy (Chow, 2015).
Diagnosis:
K27 Peptic Ulcer Disease
K21.9 Gastro-esophageal reflux disease without esophagitis
K29.70 Gastritis, unspecified, without bleeding
Source: ICD10Date.com, 2017.
Differential Diagnosis:
Diverticulitis
Emergent Treatment of Gastroenteritis
Esophageal Rupture and Tears in Emergency Medicine
Esophagitis
Gallstones (Cholelithiasis)
Gastroesophageal Reflux Disease
Inflammatory Bowel Disease
Viral Hepatitis
Acute Cholangitis
Acute Coronary Syndrome
Acute Gastritis
Cholecystitis
Cholecystitis and Biliary Colic in Emergency Medicine
Chronic Gastritis
Source: Epocrates, 2017.
Plan of Care:
Initially, this patient was started on over the counter antisecretory treatment such as an histamine-2 receptor antagonist or a proton pump inhibitor therapy (PPI) (NIH, 2014). At follow up, patient reported no relief in symptoms and tested positive for H. pylori. He was then treated with standard triple therapy (American Family Physician, 2015). At the next follow up he stated that symptoms resolved during antibiotic triple therapy but returned after finishing the regimen. He was then placed on salvage therapy with included another antibiotic, Levofloxacin, a PPI and amoxicillin for 10 days. At follow up the patient was completely symptom free. The patient was educated regarding possible continuation of PPI therapy to alleviate continuing symptoms. He was counseled to avoid NSAIDS, alcohol, spicy foods, smoking and to avoid lying down after eating (American Academy of Family Physicians [AAFP], 2015)
The patient was counseled and educating using the services of a Spanish speaking interpreter and was given Spanish medication and treatment handouts. He was given instructions to recognize worsening symptoms and when to follow up in office.
Medications:
Triple Therapy:
Omeprazole (PPI): 40mg PO QD for 4 weeks
Amoxicillin: 1g PO BID for 10 days
Clarithromycin 500mg PO BID for 10 days
Second Line:
Omeprazole (PPI): 40mg PO QD for 10 days
Amoxicillin: 1g PO BID for 10 days
Levofloxacin 500mg PO QD for 10days
References:
American Academy of Family Physicians (2015). Diagnosis and Treatment of Peptic Ulcer Disease andH. pyloriInfection. American Family Physicians. 91(4):236-242. Retrieved from URL: https://www.aafp.org/afp/2015/0215/p236.htm
American College of Gastroenterology (2017) Peptic Ulcer Disease. Digestive Health Topic. Retrieved from URL: http://patients.gi.org/topics/peptic-ulcer-disease/
Chow, S. (2015). Peptic Ulcer Diagnosis. News Medical Life Sciences. Retrieved from URL: https://www.news-medical.net/health/Peptic-Ulcer-Diagnosis.aspx
Epocrates (2017). Peptic Ulcer Disease. Retrieved from URL: https://online.epocrates.com/diseases/8035/Peptic-ulcer-disease/Differential-Diagnosis
ICD0Data.com (2017). Gastro-esophageal reflux disease without esophagitis. Retrieved fromhttp://www.icd10data.com/ICD10CM/Codes/K00-K95/K20-K31/K21-/K21.9
ICD10Data.com (2017). Peptic ulcer, site unspecified. Retrieved fromhttp://www.icd10data.com/ICD10CM/Codes/K00-K95/K20-K31/K27-/K27
ICD10Data.com (2017). Gastritis, unspecified, without bleeding. Retrieved from URL: http://www.icd10data.com/ICD10CM/Codes/K00-K95/K20-K31/K29-/K29.70
National Institutes of Health [NIH] (2017). Upper GI Endoscopy. Diagnostic Tests. Retrieved from URL: https://www.niddk.nih.gov/health-information/diagnostic-tests
SOAP NOTE
Name:
Date:
Time:
Age:
Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care in quotes
HPI:
Describe the course of the patients illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications:
(list with reason for med )
PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.
Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:
lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats, energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, edema
Skin
Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB
Eyes
Corrective lenses, blurring, visual changes of any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools
Ears
Ear pain, hearing loss, ringing in ears, discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of urine.
Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis
Breast
SBE, lumps, bumps or changes
Neurological
Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx
OBJECTIVE
Weight BMI
Temp
BP
Height
Pulse
Resp
General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.
Skin
Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.
Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.
Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genitourinary
Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.
Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable.
(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )
(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or massesMales: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).
Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Urinalysis pending
Urine culture pending
Wet prep – pending
Special Tests
Diagnosis
Differential Diagnoses
o 1- o 2- o 3-
Diagnosis
o
Plan/Therapeutics
o Plan:
Further testing
Medication
Education
Non-medication treatments
Evaluation of patient encounter
