NSG6420 Week 4 SOAP

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School

South University, Savannah *

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6420

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Medicine

Date

Feb 20, 2024

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docx

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SOAP NOTE Student Name: Course: NSG6420 Name: Date: Time: 1115 Ethnicity: White Age: 39 Sex: M SUBJECTIVE CC: “I have been having pain/burning in my chest and sour taste in my mouth” HPI: The patient is a 39-year-old white male who presents with a chief complaint of epigastric pain and a sour taste in his mouth. He reports that the pain is intermittent and often occurs after meals, with a duration of approximately two months. The patient describes the pain as a burning sensation and rates its intensity as moderate. He denies any radiation of pain and reports occasional regurgitation of stomach contents with a sour taste. No associated symptoms such as dysphagia, weight loss, or changes in bowel habits are reported. Medications: (list with reason for med ) None PMH Allergies: NKA Medication Intolerances: None Chronic Illnesses/Major traumas: Denies Hospitalizations/Surgeries- Appendectomy Family History M: Alive- Type 2 Diabetes, hyperlipidemia MGM: Deceased MGF: Deceased- Colon Cancer F: Alive- hypertension

PGM: Alive PGF Alive Social History The 39-year-old white male is currently single and resides in an apartment, having worked in an insurance office for 10 years. He completed his education up to an associates degree. The patient has a supportive social network and engages in pickle ball for exercise and yoga for relaxation. There is no history of tobacco or illicit drug use, and he reports minimal alcohol consumption without any abuse . ROS General Patient denies nights sweats and fatigue Cardiovascular Denies any chest pain or shortness of breath. Skin No rash, lesions, or other skin abnormalities Respiratory Denies shortness of breath, reports chest congestion, productive cough Eyes Denies any visual changes, complains of pain behind bilateral eyes Gastrointestinal Reports heart burn and regurgitation of food, Denies abdominal pain, nausea, vomiting or diarrhea Ears Denies ear pain or hearing loss Genitourinary/Gynecological Denies discharge, dysuria hematuria. Nose/Mouth/Throat Musculoskeletal

Reports persistent sour taste in the mouth. Denies loss of smell, sore throat, reports nasal discharge and congestion Denies pain to extremities or difficulty ambulating Breast Denies pain or discomfort Neurological Denies syncope, seizures, headache, or dizziness Heme/Lymph/Endo Denies bleeding, no enlarged lymph nodes Psychiatric Denies depression, anxiety, SI or sleeping difficulty OBJECTIVE Weight 77kg BMI 24.29 Temp 37.1 BP 136/78 Height 5’10 Pulse 65 Resp 18 General Appearance The 39-year-old well-mannered white male presents with a neat and groomed appearance. He maintains appropriate eye contact, exhibits calm demeanor, and cooperates effectively during the examination, demonstrating an overall composed and respectful attitude. Skin Skin in clean, dry and intact. HEENT Head is normocephalic, atraumatic. Eyes: Pupils are equal, round, and reactive to light, vision grossly normal. Ears: Canals patent. Bilateral tympanic membranes clear, landmarks easily visualized. Nose: Nasal mucosa red; normal turbinates. No septal deviation. Tenderness present on palpation at the sinus maxillary and frontal sinus Neck: Supple. Full ROM; trachea midline. Mouth/throat: Oral mucosa is moist and pink. Teeth are in good repair . Pharynx appears red without any erythema or exudate. The uvula is midline. The tonsils are without enlargement or evidence of inflammation. Cardiovascular Normal rhythm and rate, characterized by clearly audible S1 and S2 heart sounds. No additional auscultatory findings, including murmurs, rubs, or clicks, are noted. Absence of edema is observed, and pulses are uniformly assessed as 3+. Capillary refill time is measured at a brisk two seconds. Respiratory Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal Gastrointestinal Abdomen is slim and symmetrical, soft, non-tender, no guarding or rebound tenderness, bowel sounds present in all four quadrants Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin .

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Genitourinary Bladder appears relaxed without signs of distension; no CVA tenderness Musculoskeletal Normal ROM, normal strength in bilateral legs and arms Neurological Alert and oriented to person, place, time and situation, no focal neurological deficit observed, normal sensory observed, normal motor observed, normal speech observed Psychiatric Cooperative, appropriate mood and affect, maintains eye contact Lab Tests EKG- performed in house- NSR Special Tests N/A Diagnosis  K21.9- Gastroesophageal Reflux Disease (GERD) is a chronic condition marked by the abnormal reflux of stomach acid into the esophagus due to a weakened lower esophageal sphincter (LES). Common symptoms include heartburn, regurgitation, and a sour taste. Lifestyle changes, medications (such as proton pump inhibitors), and, in some cases, surgery are used for management (Clarrett & Hachem, 2018). Differential Diagnoses 1. K27.9- Peptic Ulcer Disease is a condition characterized by the development of open sores (ulcers) on the inner lining of the stomach or the upper part of the small intestine. Common causes include infection with Helicobacter pylori

bacteria and the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Peptic ulcers can cause symptoms such as burning abdominal pain, bloating, nausea, and, in some cases, bleeding. Diagnosis often involves endoscopy, and treatment may include medications to reduce stomach acid, antibiotics for H. pylori eradication, and lifestyle modifications (Malik et al., 2023). 2. K44.9- Hiatal hernia occurs when a portion of the stomach protrudes through the diaphragm and into the chest cavity. This displacement of the stomach through the diaphragmatic opening, called the hiatus, can lead to symptoms such as heartburn, regurgitation, and chest pain. Hiatal hernias are often classified as sliding or paraesophageal, with sliding hernias being more common (Sfara & Dumitrascu, 2019). While some individuals with hiatal hernias may remain asymptomatic, others may experience gastroesophageal reflux disease (GERD) symptoms. Plan/Therapeutics Plan Diagnostic Tests: - Referred for upper endoscopy to evaluate the esophagus and stomach lining. - Sent to perform Helicobacter pylori testing to rule out bacterial infection. - Referred for an abdominal ultrasound to assess for any structural abnormalities. Treatment: - Proton pump inhibitor (PPI) therapy Omeprazole 40mg daily to reduce gastric acid production. - Lifestyle modifications, including dietary changes and elevation of the head of the bed. - Follow-up appointment in two weeks to assess response to treatment and discuss further management. Evaluation of patient encounter The patient was seen in the clinic for a comprehensive evaluation of epigastric pain and sour taste in his mouth. A detailed history was obtained, focusing on the nature, duration, and aggravating/alleviating factors of his symptoms. Physical examination and vital signs were performed to assess the patient's overall health. Based on the initial assessment, three potential differential diagnoses were considered, and a comprehensive plan was developed, including diagnostic tests and a treatment regimen. The patient was educated about lifestyle modifications and the importance of follow-up to monitor treatment efficacy. Further investigation and close monitoring will be crucial in determining the underlying cause of the patient's symptoms and guiding ongoing management. References

Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal Reflux Disease (GERD). Missouri medicine, 115(3), 214–218. Malik, T. F., Gnanapandithan, K., & Singh, K. (2023, June 5). Peptic Ulcer Disease. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK534792/ Sfara, A., & Dumitrascu, D. L. (2019). The management of hiatal hernia: an update on diagnosis and treatment. Medicine and pharmacy reports, 92(4), 321–325. https://doi.org/10.15386/mpr- 1323

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NSG6420 Week 4 SOAP

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