Soap Note

Reason given by the patient for seeking medical care “in quotes”

“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.”

Describe the course of the patient’s 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.

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.

Allergies: No known drug allergies

Medication Intolerances: Takes ibuprofen “almost daily” for aches and pains associated with working. Drinks herbal tea meant to improve GI symptoms.

Chronic Illnesses/Major traumas: Not indicated

Hospitalizations/Surgeries: No history of surgery.

lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

Patient states family history of heart disease. Father had hypertension and his mother had diabetes.

Patient denies smoking. Patient states that he quit smoking 6 months ago. Patient states that he drinks 3-4 beers weekly.  No illicit drugs.

Weight change, fatigue, fever, chills, night sweats, energy level

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.

Chest pain, palpitations, PND, orthopnea, edema Regular heart rate and rhythm. S1, S2, no murmurs, rubs, or gallops.

No change in skin, hair or nails.

Clear to auscultation.

No change in vision

Soft, flat, non-distended. Normative 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.

No ear problems

Denies problems with urination.

No nose problems, nor sore throat

Alert & oriented x3. Denies muscle, back pain, joint pain or stiffness.

No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

No enlarged nodes. Denies history of splenectomy.

Denies history of depression or anxiety. Patient does express concern about paying for medications and follow up visits due to lack of insurance.

Patient is alert, oriented and is cooperative.

No change in skin, hair or nails.

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.

Regular heart rate and rhythm. S1, S2, no murmurs, rubs, or gallops.

Clear to auscultation.

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.

Denies problems with urination.

Alert & oriented x3. Denies muscle, back pain, joint pain or stiffness.

No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

Denies history of depression or anxiety. Patient does express concern about paying for medications and follow up visits due to lack of insurance.

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.

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.

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.

· 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

Diagnosis

· K27 Peptic Ulcer Disease

· K21.9 Gastro-esophageal reflux disease without esophagitis

· K29.70 Gastritis, unspecified, without bleeding

· Further testing

Initially, this patient was started on over the counter antisecretory treatment such as a 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. 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

· Medication

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

· Education

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.