SOAP GI
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Florida College *
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Course
380
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
3
Uploaded by PresidentPowerRaven21
SOAP GI
Identifying info:
LC
F
DOB 08/14/1999
SUBJECTIVE
CC:
Can’t swallow foods
HPI:
Patient is a 24-year-old well-nourished Hispanic female. She presents with inability to
swallow foods which started 4 days ago while she was trying to have breakfast. It is a constant
complain and finally came in once she realized it didn’t go away. She described it as a rock in her
throat which feels hard. Patient stated that whenever she opens her mouth and tries to chew, it
makes her gag from not being able to swallow foods. She stated there is no relieving factors or
treatments for her illness, except for substituting liquids such as smoothies.
Patient stated there is no pain. She states it affects her ability to eat real food and is hungry
constantly.
.
PMH:
01/20/2021
LC, a 21-year-old female, presents with recurrent stomach ulcers that have
been occurring for the past 6 months. These ulcers are small, painful sores located on the inside
of
left stomach. They last for about a week and tend to reoccur every few weeks, often
triggered by certain foods or stress. The patient states it feels like a hot flash that pains in her.
Whenever she eats hot, spicy foods it makes the pain worse. While having cold tea makes it
better. LC takes omeprazole 20 mg tablet every 24 hours to relieve herself of the pain. She has
no other known medical history.
FH:
Mother diagnosed with kidney disease at age 35.
Meds:
OTC Omeprazole 20 mg tablet by mouth. Patient took this medication within 01/2021 to
07/2021 to relieve herself of stomach ulcers. Patient states of no side effects from it.
Allergies:
NKA
Social History:
LC is single and has never been married. She lives in a low-rise apartment in
downtown New York. She majored in marketing at Emory University and works within the scope
of marketing as head of social media department. Patient feels safe in her apartment and
partakes in barre classes on the weekends to cope with her long hours at work. LW has a dog for
support system. Patient denies any current stressors. The patient identifies Roman catholic but
does not find spirituality as important. Denies any recreational, alcohol, and tobacco use. Her
typical daily meals include one cup of egg whites with a slice of whole wheat toast and a cup of
mixed bananas and blueberries for breakfast. For lunch, she enjoys a spinach wrap filled with
three turkey slices, two slices of pepper jack cheese, and 3 cups of spinach, paired with one cup
of 3 sliced yellow peppers and two tablespoons of regular cream cheese. Dinner typically
consists of one chicken breast, two cups of mixed vegetables, and one cup of white rice.
Throughout the day, she incorporates snacks, such as a cup of goldfish or packet of seaweed.
She consistently consumes 65 ounces of water daily within her meals and one 8 oz cup of
orange juice for breakfast.
Enjoys 40-minute walks in the park in the afternoons with her dog.
She maintains an active lifestyle by engaging in hour-long Pilates sessions four times a week.
Stated she sleeps 7 hours a day with no findings in snoring and updates her online shopping
wish list before bed.
ROS:
GI:
Positives:
changes in weight loss. LC , a 24-year-old female, presents with a chief complaint of
significant difficulty swallowing, which led to weight loss within the past few days. She has felt
this weight loss change in her low abdomen. It is a constant discomfort and hungriness. It makes
it worse when she smells food, but better when she keeps herself occupied from any duties.
Patient has no treatment for the changes. The patient rates the pain and discomfort associated
with swallowing as a 7 out of 10.
Negatives:
denies urinary frequency, changes in urine color, food sensitivities, as well as
constipation/diarrhea. No black stools, rectal bleeding, jaundice, hematuria, and
nocturia/dysuria.
OBJECTIVE
VS
T 98.2
P 65
RR 20
BP 110/75
HT
5 ft 3 in
WT
125 lbs
General Survey:
24-year-old, well-groomed woman. Dressed appropriately with clean parted
hair that appears normal for age and ethnicity. She is alerted and orientated but
occasionally
bends over from discomfort. Weight and height are within normal range of body structure for
age stated. Speech is clear and comfortable on bed laying down.
PE:
GI:
Abdomen is flat, symmetric with no apparent masses, lesions, or scars. No pulsations noted
on inspection. Skin is appropriate for ethnicity. Distribution of hair is WDL. Tympany bowel
sounds in lower quadrants. Positive for pain in stomach when inspected with deep palpitations.
No masses. But tenderness in all 4 quadrants.
ASSESSMENT
24-year-old woman with the following:
1.
Inability to swallow foods
2.
HX of ulcers
3.
FH of kidney disease
4.
Weight changes
PLAN
1.
Consult with main provider to see if acid reflux medications will work
2.
Acknowledge to avoid hot and spicy foods from diet
3.
Get tested to see if there is any signs or symptoms that could result in kidney disease
4.
Educate in having protein in smoothies in the meantime if swallowing inability occurs to
avoid any more weight lost
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