Comprehensive SOAP Note:Case study assessment-solution<\/h2>\n
Comprehensive SOAP Note
\nCriteria Critical Notes
\nSubjective Name: Trevor McKinley
\nDOB: 21\/05\/1968
\nGender: Male
\nMarital status: Divorced
\nAccompanied by: None
\nCC: “I have a recurrent heartburn and pain swallowing food.”<\/p>\n
History of present illness: The patient is a 53 years old African American male who lives in Chicago, Illinois. He is divorced and lives with his two sons, aged 25 and 14. He owns an audit firm and a retail store. The patient complains of a chronic cough, nausea, frequent heartburns, sour-bitter taste at the back of his mouth, pain when swallowing food, bad breath, and chest pains. He also reports that his health improved after he enrolled at a nearby fitness center, but his firm has become busy recently, making it difficult to spare some time for workouts. He only has a few employees and does most of the work himself. He spends most of the time at the firm and passes by his store on his way home, continuing with his work. He has also relapsed to smoking, where he takes two packets of cigarettes per week. Although he had previously quit smoking, he states that smoking helps relieve anxiety caused by work pressure.(Comprehensive SOAP Note:Case study assessment)<\/p>\n
Past medical history: The patient visited the clinic six months ago due to hypertension. He had been given an appointment one month after treatment but did not follow up due to work travel. He claims that the Cardizem dose he was prescribed effectively treated his condition and did not feel the need to seek any other treatment.(Comprehensive SOAP Note:Case study assessment)<\/p>\n
Current medication: None prescribed.
\nAllergies: denies having any food, drugs, or environmental allergies.
\nSocial History: He divorced his wife five years ago and has been single since. The patient lives with his two sons and brother.
\nFamily history
\nFather- 87 years, Type II diabetes
\nMother- Died of a cardiac arrest at 65 years.
\nBrother-30 years, Type II Diabetes.
\nSons- healthy<\/p>\n
Review of Systems
\n\u2022 General: Denies fever and chills. Confirms appetite changes and weight gain.
\n\u2022 Head, eyes, ears, nose, and throat: The patient has trouble swallowing but denies smell, vision, and hearing changes.
\n\u2022 Integumentary: Denies any skin rashes, lesions, wounds, and changes.
\n\u2022 Cardiovascular: The patient has chest pain.(Comprehensive SOAP Note:Case study assessment)
\n\u2022 Lungs: The patient has breathing difficulties.
\n\u2022 Gastrointestinal: The patient has nausea and abdominal pain denies vomiting, constipation, diarrhea.
\n\u2022 Genitourinary: Denies urinary frequency and difficulty in urination.
\n\u2022 Peripheral vascular: Denies peripheral edema of all extremities.
\n\u2022 Musculoskeletal: Denies any injury, joint, or muscle pain.
\n\u2022 Neurological: Denies headaches, dizziness, confusion, or weakness.
\n\u2022 Endocrine: Denies endocrine issues(Comprehensive SOAP Note:Case study assessment)
\n\u2022 Skin- Denies any skin issues.
\nObjective Vitals: Height 5’9″ Weight 207 BMI 30.6, PR 89 BPM, Temp: 98.6 F, reports pain 2\/10.
\nLabs: Blood test results 128\/75mmHg.<\/p>\n
Physical examination:
\n\u2022 Appearance: Well-groomed, no acute distress, cannot maintain a straight sitting position.
\n\u2022 Cardiovascular- slightly faster heart rate, breath sounds present, and no murmur noted.
\n\u2022 Respiratory- Breaths sounds present.
\n\u2022 Gastrointestinal- No hernia observed; the abdomen is hard.(Comprehensive SOAP Note:Case study assessment)
\n\u2022 Speech: Spontaneous, appropriate rate, appropriate tone, and low volume without pressured speech, with some problems expressing self
\n\u2022 Eye contact: Intermittent
\n\u2022 Motor Activity: Has trouble with movement.
\n\u2022 Affect: Full, even, and congruent with mood
\nMood: “Good”
\nBehavior: Cooperative and conversant
\nAssessment Diagnosis
\nHypertension I10
\nObesity E66.9
\nGastroesophageal reflux disease K21.9
\nDifferential Diagnosis
\nGastroesophageal reflux disease K21.9
\nPeptic Ulcer disease K27.2
\nGastritis K29.70
\nCoronary Artery Atherosclerosis I25.10
\nThe patient’s health has declined based on his medical records.<\/p>\n
Final Assessment
\nThe patient is suffering from Gastroesophageal reflux disease based on the symptoms presented. The condition is associated with heartburn, a sore taste at the back of the mouth, chest pains, and regurgitation of liquids or food from the stomach to the mouth (Lim et al., 2018). In other cases, the patient may present a hoarse voice, pain or difficulty swallowing food, a chronic cough, and bad breath (Savarino et al., 2020). Additionally, the patient is obese, which increases his risk of the condition. Nonetheless, his condition has worsened due to a relapse of his smoking behavior and reduced physical activity (Savarino et al., 2021). The patient spends most of his time in the office and no longer goes for his workout sessions which have worsened his health.(Comprehensive SOAP Note:Case study assessment)
\nNonetheless, his hypertension should be treated to avoid complications. He has previously prescribed 30mg of Cardizem four times before meals and bedtime. He was supposed to visit the clinic for further assessment and dosage increase, but he did not. He believed his condition improved, but lack of follow-up may have worsened his condition as he did not follow the dosage as prescribed. I ruled out coronary artery atherosclerosis because although the patient had chest pains, he did not present cramping, leg pain, fatigue, confusion, or muscle weakness. Also, the patient did not present any fullness, belching, or bloating symptoms of Peptic Ulcer Disease (Savarino et al., 2020). Lastly, he did not present any feeling of fullness in the upper abdomen, a core symptom of Gastritis (Lim et al., 2018).(Comprehensive SOAP Note:Case study assessment)
\nSome potential medications to treat Gastroesophageal reflux disease are H2 blockers, PPIs anti-acids, and medical procedures. H2 blockers help to lower the acid levels made in the stomach. Additionally, proton pump inhibitors, also known as PPIs, also lower the stomach’s amount of acid, treating the Gastroesophageal reflux disease symptoms (Savarino et al., 2020). It is considered more effective than H2 inhibitors as they can heal the esophageal lining of the patients. It is preferred for long-term treatment of the condition. PPIs are also safe and have fewer side effects.(Comprehensive SOAP Note:Case study assessment)
\nNonetheless, the Gastroesophageal reflux disease may be treated through fundoplication, one of the most common surgeries for the condition (Lim et al., 2018). This procedure helps to enhance a long-term improvement of the symptoms. Also, bariatric surgery is highly recommended when a patient has Gastro-esophageal reflux disease and obesity. This procedure helps to enhance weight loss while reducing GERD symptoms (Savarino et al., 2020). From this assessment, I think the best medication for the patient is PPIs. Based on the extent of his condition, H2 inhibitors may be less effective for his condition. He is also against surgery and prefers working out to having a weight loss procedure.(Comprehensive SOAP Note:Case study assessment)
\nTreatment Goals
\n1. Gastroesophageal reflux disease K21.9- reduce symptoms prevent relapse and esophagitis complications (Lim et al., 2018).
\n2. Hypertension I10- BP of <130\/80mmHg to avoid the risk of cardiovascular disease.
\n3. Obesity E66.9- Adopt a healthy lifestyle to avoid excessive weight gain.
\n4. The patient seems to understand the importance of medication prescribed and is willing to adhere to the treatment plan, unlike the last visit.
\n5. Also reviewed the potential benefits and risks for PPIs and alternatives to treatment.
\nPlan Therapeutics
\n\u2022 Pharmacological
\nPrescribe proton pump inhibitors (PPIs) – take pantoprazole 40mg once a day for two months. The patient should take the medication orally in the morning at least 30 minutes before food intake.
\n\u2022 Non-pharmacological
\nWeight loss
\nEngage in regular physical activity- aerobics for 90-150 minutes per week
\nTake small frequent meals and increase potassium intake.
\nReduce sodium intake.
\nAvoid smoking
\n\u2022 Education(Comprehensive SOAP Note:Case study assessment)
\nEducate the patient on the need to adhere to the medication prescribed.
\nProvide dietary information.
\nGuide the patient on monitoring his blood pressure at home in the morning and evening for one week and record the findings for easier monitoring. He should also bring the blood pressure record during his next visit.
\nEducate the patient on the sComprehensive SOAP Note:Case study assessmentymptoms he should look for, indicating the need for urgent care.(Comprehensive SOAP Note:Case study assessment)
\nEducate the patient on the risk factors of gastroesophageal reflux and hypertension alongside the disease symptoms to help prevent adverse outcomes.(Comprehensive SOAP Note:Case study assessment)
\nEnsure the patient is aware of the complications associated with hypertension, including stroke and heart attack.
\n\u2022 Collaboration\/Consultation(Comprehensive SOAP Note:Case study assessment)
\nConsult a dietician to help develop a meal plan to help the patient lose excess weight.
\nFollow up
\nEvaluation with a provider in one week to review the blood pressure levels. Visit the clinic in case symptoms are not relieved.(Comprehensive SOAP Note:Case study assessment)<\/p>\n
![\"Comprehensive](\"https:\/\/nursingstudy.org\/examples\/wp-content\/uploads\/2023\/05\/download-2023-05-22T142803.607.jpg\")
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References
\nLim, C. H., Lee, P. C., Lim, E., Tan, J., Chan, W. H., Tan, H. C., Ganguly, S., Tham, K. W., & Eng, A. (2018). Correlation between symptomatic gastroesophageal reflux disease (GERD) and erosive Esophagitis (EE) post-vertical sleeve gastrectomy (VSG). Obesity Surgery, 29(1), 207-214. https:\/\/doi.org\/10.1007\/s11695-018-3509-0
\nSavarino, V., Marabotto, E., Zentilin, P., Furnari, M., Bodini, G., De Maria, C., Tolone, S., De Bortoli, N., Frazzoni, M., & Savarino, E. (2020). Pathophysiology, diagnosis, and pharmacological treatment of gastroesophageal reflux disease. Expert Review of Clinical Pharmacology, 13(4), 437-449. https:\/\/doi.org\/10.1080\/17512433.2020.1752664
\nSavarino, V., Marabotto, E., Zentilin, P., Demarzo, M. G., De Bortoli, N., & Savarino, E. (2021). Pharmacological management of gastroesophageal reflux disease: An update of the state-of-the-Art. Drug Design, Development, and Therapy, 15, 1609-1621. https:\/\/doi.org\/10.2147\/dddt.s306371<\/p>\n
https:\/\/www.ncbi.nlm.nih.gov\/<\/p>\n","protected":false},"excerpt":{"rendered":"
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