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 and H. pylori Infection. 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