SOAP_NOTE_Peptic_ulcer

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Dec 6, 2023

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NOTE: All cases must be developed in primary health care, not at the hospital level. ( Student Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Ciro A. Ramirez/ South FL MD Group Clinical Instructor: Leonardo Trobajo Lobayna, Professor at MSN/FNP Program Soap Note # ____ Main Diagnosis _Peptic Ulcer PATIENT INFORMATION Name : S.J Age : 21 Gender at Birth: F Gender Identity : F Source : Patient Allergies : NKFDA. Current Medications:  Advil 400mg after every 4-6 hours as needed. PMH: None Immunizations: COVID-19 vaccine- 7/26/2022 Influenza vaccine - 6/3/2018 Preventive Care : None Surgical History : None Family History : Father-Alive and healthy. Mother alive and healthy.

Social History : S.J is a college student and lives alone in her rented apartment. She reports active lifestyle and works part-time as a store attendant. She states the she is a Christian but does not attend church services regularly. No recreational drugs or smoking reported, but reports occasional alcohol consumption. Sexual Orientation : Heterosexual. Nutrition History : She states that she hardly cooks and mostly orders fast foods from her favorite restaurants. Subjective Data: Chief Complaint : “Pain in the upper part of my abdomen” Symptom analysis/HPI: S.J is a 21-year-old Latino female who reported to the clinic with a complaint of upper abdominal pain. She stated that her pain is on the mid-epigastric region. She states that the pain started a week ago and reports feeling burning sensation, bloating, and easy fullness after eating small quantities of food. The pain starts after taking a meal. The pain was 7/10 before taking over the counter Advil 400mg for pain relief. She states that the pain now is at 4/10. She stated that the pain mostly begins after eating, but she is not convinced that the food could cause any pain. The pain is relieved by medication and sleeping. She reports nausea and lack of appetite. Review of Systems (ROS) ( This section is what the patient says, therefore should state Pt denies, or Pt states….. ) CONSTITUTIONAL : Pt. denies fatigue, weakness, syncope, and unintentional weight loss. Denies shakiness, dizziness, fevers, headache and sweating at night. NEUROLOGIC : Pt denies numbness or tingling.

HEENT : Pt denies headaches. Denies blurry and double vision or any visual changes. Denies ear discharge, pain, ringing ears or loss of hearing. Denies nose sinus, bleeding, and sore throat. RESPIRATORY : Pt denies wheezing, T.B. or pneumonia hx. Denies coughing and dyspnea. CARDIOVASCULAR : Pt denies chest pain and palpitations. Denies edema and orthopnea. GASTROINTESTINAL : Pt states abdominal pain and black tarry stools. Pt states nausea, and vomiting, and constipation. GENITOURINARY : Pt denies urgency, hematuria, burning with urination, change in urine color and STD. MUSCULOSKELETAL : Pt denies stiffness, joint pain, fractures. Denies swelling feet and slowed movement. SKIN : Pt denies bruises, loss of skin color, skin rash, lesions, and itching. Objective Data: VITAL SIGNS: HR-70, RR-18, Temp-97.5, BP 118/78. Ht-70”, Wt-177 lbs. BMI-25.4, Pain 4/10 GENERAL APPEARANCE : Healthy appearing young female who is well-groomed. She is in slight distress. NEUROLOGIC: Patient communicates in a normal tone and follows commands appropriately. Alert and oriented x4. HEENT: Head is normal; no lesions, black hair distributed evenly, autraumatic and normocephalic. Eyes: EOMs, PERRLA. No sclera or conjunctival injection. Ears: Bilateral T.M.s pearly grey with normal flex, seen easily. Nose: normal pink mucosa and turbinates. No septal

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deviation. Neck: Full ROM, no sore throat or swollen glands. The oral mucosa is moist and pink. Clean teeth and well-organized. CARDIOVASCULAR: No heart murmurs. No irregular radical pulse to palpitation. S1, S2 regular rhythm and rate. No edema. RESPIRATORY: no occasional coughing. No bubbling sound in bilateral lung bases. No wheezing, even chest movement with respirations. GASTROINTESTINAL: B.S. active in all 4 quadrants. Non-distended abdomen. No hepatosplenomegaly. Pain in the epigastric region. No tenderness to percussion and palpitation MUSKULOSKELETAL: Full ROM in all extremities when patient moves around. INTEGUMENTARY: No clubbing of finger or toenails. Warm skin with no lesions or bruises ASSESSMENT: The patient reported to the clinic with a complaint of abdominal pain producing burning sensation around the epigastric region, which start after taking a meal. She reports nausea, lack of appetite, bloating, and early satiety. The patient stated that the pain started a week ago. The patient stated that she used pain relief medication and sleeps to relief the pain. Based on the objective data, the patient symptoms aligned with subjective data report. Main Diagnosis Peptic ulcer (ICD-10 code: K27.4). This is a condition associated with discontinuation in the inner lining of the GI system as a result of secretion of gastric acid (Malik et al., 2019). Most cases of peptic ulcers are associated with Helicobacter pylori infection and medicines. While some patients with peptic ulcers are asymptomatic, those found to be symptomatic often show epigastric pain, bloating, early satiety, nausea, and abdominal fullness (Kevitt et al., 2019). The

rationale for this diagnosis is the patient’s symptoms, particularly abdominal fullness, early satiety, and pain in the epigastric region. Differential diagnosis ( minimum 3, only differential diagnoses with CD-10 code, no explanation of each one needed)  Dyspepsia (ICD 10 code: K30)  Gastroesophageal reflux disease (ICD-10 code: K21.9)  Gastritis (ICD- 10 code: K29.70) PLAN: Labs and Diagnostic Test to be ordered (if applicable)  Complete blood count to check for Leukocytosis. Results: Postive.  Stool antigen test for H. pylori. Results: Positive.  Upper gastrointestinal (GI) endoscopy. Results: Stomach ulcer present. Pharmacological treatment:  Pantoprazole 40 mg 3 times daily for 7 days.  Amoxicillin 1,000 mg twice daily for 7 days.  Clarithromycin 500 mg twice daily for 7 days.  Advil 400 mg after every 4-6 hours as needed for pain. Non-Pharmacologic treatment :  The patent should avoid junk food, especially deep-fried and processed foods, and avoid acidic foods and drinks, which increase acid production or irritate the stomach lining, such as carbonated beverages, alcohol, and coffee.  Drinking plenty of water (at least 8 glasses). Education ( provide the most relevant ones tailored to your patient)

 Teaching the patient about maintaining a healthy diet including plenty of fruits, vegetables, and fiber foods, and not to take any meals that cause discomfort to them (Kevitt et al., 2019).  Teaching the patent to adhere to treatment regimen as prescribed, even when the symptoms go away.  Pt. advised to avoid carbonated or acidic drinks.  The patient should avoid alcohol at all. Follow-ups/Referrals  Pt. to report to the clinic if the symptoms persist or recur. References (in APA Style) Kavitt, R. T., Lipowska, A. M., Anyane-Yeboa, A., & Gralnek, I. M. (2019). Diagnosis and treatment of peptic ulcer disease. The American Journal of Medicine , 132 (4), 447-456. https://doi.org/10.1016/j.amjmed.2018.12.009 Malik, T. F., Gnanapandithan, K., & Singh, K. (2018). Peptic ulcer disease. StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534792/

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