Week 4: GERD SOAP Note Assignment Solution
GERD SOAP Note
| Data Needed | Data for this patient |
| Patient Initials | B. W. |
| Identifying Data | Male, Caucasian |
| Source and Reliability | Patient with a capacity to answer questions |
| Age | 45 years |
| Gender | Male |
| Occupation | Social worker |
| Marital Status | Married |
| Subjective | |
| Chief complaint or appropriate health screening visit: | The patient presented at the clinic complaining of abdominal discomfort for the past three days. He said it feels like a “burning sensation in my chest.” |
| History of Present Illness: | Mr B.W. is a 45-year-old Caucasian male with a medical history of hyperlipidemia, hypothyroidism, hypertension, and DM Type II. The patient complained of abdominal discomfort ranging from 5 to 6 out of 10 for three days. The patient states that he has experienced stomach discomfort for the past three days, describing it as burning pain from the mid-abdomen and rising to the middle of his chest. He stated that the pain usually commences when he eats and worsens when lying down, but it is minimal when walking. Mr. B.W. denies constipation or diarrhea. His last meal was at noon today. The patient reports that his primary care physicians advised him to start taking aspirin once a day. |
| Past Medical History: | Current Medications: Atorvastatin (Lipitor) 40 mg tablet every nightLevothyroxine (SYNTHROID) 100 mcg once a dayMetformin (GLUCOPHAGE) 500 mg tablet twice a dayAspirin 81mg once daily Allergies: No known allergies PMHx: Diabetes mellitus (managed by eating a healthy diet and adhering to medication) Diabetes type 2 (managed by eating a healthy diet and adhering to medication) Hyperlipidemia (on medication treatment) Hypothyroidism (on medication treatment) Health Maintenance: Immunization: Patient reports immunization every year up to age 12. The most recent immunization is 2021 for Covid-19 Dental exam: Patient reports occasional dental visits, the last being in January 2020. Reports cavities on the left-lower premolars. Eye exam: Patient reports that he went for an eye exam once in 2018. No significant medical condition. Testicular exam: No reports of any testicular exam. |
| Family History: | The patient has a wife and two children, a boy aged four and a girl aged 7. Patient reports that his wife and children have no significant medical history. Both parents are reported alive, the father with high blood pressure and the mother with osteoporosis. |
| Personal and Social History: | The patient reports that he graduated from college with a degree in public health. The patient likes to read and play the guitar during free time and after work. The patient states he is less physically active but tries to maintain a healthy diet to manage diabetes. He performs activities of daily living without assistance. The patient reports drinking ETOH occasionally, about 2-3 cans of beer twice a week. Denies smoking and illicit drug use. |
| Review of Systems: | General: A&O x4, pleasant and cooperative. Reports abdominal pain 5-6/10. No acute distress. Denies weight loss, weakness, or fatigue. HEENT: Denies headache, sore throat or changes in hearing. SKIN: No rash or itching. CARDIOVASCULAR: Reported burning sensation on his chest when lying down. RESPIRATORY: Denies shortness of breath or cough. GASTROINTESTINAL: Patient reports abdominal discomfort for the past three days ranging from 5-6/10. Described as “gnawing” and “burning.” Denies nausea or vomiting. Denies alteration in bowel pattern. GENITOURINARY: Denies dysuria or hematuria. NEUROLOGICAL: Denies focal loss of strength or loss of sensation. MUSCULOSKELETAL: Denies focal weakness, facial droop, or joint swelling. HEMATOLOGIC: Denies anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No cervical lymphadenopathy |
| Objective | |
| Vital Signs and Measurements | Vital signs: B/P 117/59 Pulse 108 (strong and regular) Temp 98.3F orally RR 18; non-labored SpO2: 96% room air Height 1.575 m (5′ 2″) weight 73.5 kg (162 lb.) BMI: 29.6 |
| Physical Examination | General: A&O x4, pleasant and cooperative. No signs of any acute distress. HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes. Neck: Supple. No JVD. Trachea midline. No pain, swelling or palpable nodules. Chest/Lungs: Clear to auscultation bilaterally. No wheezing, crackles or rhonchi. No accessory muscle use. Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally. ABD: Reports of 5-6/10 pain. Soft, non-tender, non distended. Hyperactive BS. No palpable hepatosplenomegaly Genital/Rectal: Continent of bladder and bowel. Musculoskeletal: Normal range of motion. Regular muscle mass for age. No signs of swelling or joint deformities. Neurological: Alert and oriented x4. Strength and sensation intact. Skin/Lymph Nodes: No cervical lymphadenopathy. No rashes or erythema. No lesions. Diagnostic results: EKG: NSR Laboratory studies: CBC – WBC 9.4; H/H: 14.3/41.0; PLT: 289. Chemistry Panel: BUN/Crea: 19/0.52; Glucose: 117* Pylori serology: Negative Esophageal pH Test: Pending |
| Assessment and Plan: | The patient is a 45-year-old male presenting with complaints of abdominal discomfort for the past three days, which feels like a “burning sensation in the chest.” |
| Differential diagnoses, including ICD – 10 and Rationale: | Differential Diagnoses (DD): Gastroesophageal Reflux Disease (GERD): Patient presents with a backward flow of gastric contents, typically acidic, into the esophagus (Ball et al., 2015). Patient reports a burning, gnawing pain in the mid-epigastrium that worsens with recumbence (Baumann et al., 2016). GERD risk factors are obesity, pregnancy, smoking, eating large meals or eating late at night, eating certain foods (triggers), including fatty or fried meals, drinking particular beverages like alcohol or coffee, and taking certain medications, including aspirin (Mayo Foundation for Medical Education and Research, 2017). Based on the reported signs and symptoms from subjective and objective assessment, alcohol consumption, and recent changes in the patient’s medication, GERD is the primary diagnosis for the patient. Acute coronary syndrome: A series of illnesses known as acute coronary syndrome causes a reduced blood flow to the heart. Examples include unstable angina, non-ST elevation myocardial infarction, and ST-elevation myocardial infarction (Singh et al., 2017). Most patients present with heartburn or a bitter taste in the mouth due to stomach fluid “coming up.” Typically it occurs after a meal. It is refuted because gastroesophageal reflux disease (GERD) is the most common cause of non-cardiac chest pain (The Cleveland Clinic Foundation, 2015). Peptic Ulcer: Due to pepsin or gastric acid secretion, peptic ulcer disease is characterized by the discontinuity in the GI tract’s inner lining. It penetrates the stomach epithelium’s muscularis propria layer. Usually, the stomach and proximal duodenum are affected. It might affect the distal duodenum, jejunum, or lower esophagus (Malik et al., 2018). This condition is associated with a burning or gnawing pain that often happens with an empty stomach, stress, and alcohol intake, which is relieved with food intake (Baumann, 2016). This diagnosis was refuted because most signs and symptoms are associated with GERD. Achalasia: Achalasia is a disorder where the lower esophageal sphincter remains closed while swallowing, preventing food from moving from the esophagus into the stomach. This causes food to back up, which causes symptoms like vomiting, undigested food, chest pain, heartburn, and weight loss. (The Cleveland Clinic Foundation, 2017). It is refuted because gastroesophageal reflux disease (GERD) is the most common cause of non-cardiac chest pain. Gastritis: The most common symptom of this disorder is persistent searing pain in the area of the abdomen that is sometimes accompanied by nausea, vomiting, diarrhea, or fever. Alcohol, nonsteroidal anti-inflammatory medications, and salicylates aggravate the discomfort. (Baumann, 2016). It is refuted because most symptoms are a confirmation of GERD. Hiatal Hernia with esophagitis: When the upper portion of the stomach or another internal organ protrudes through the diaphragm’s opening, it is known as a hiatal hernia. Gastric content can back into the esophagus when this gap is loose, which is the leading cause of gastroesophageal reflux disease (GERD) (Smith & Shahjehan, 2020). It is thought that age-related muscle weakness and elasticity loss predispose to developing a hiatal hernia. As a result, upon swallowing, the top portion of the stomach might not return to its regular place below the diaphragm. There are other risk factors as well, such as high intraabdominal pressure. Obesity, pregnancy, chronic constipation, and chronic obstructive lung disease are frequent causes of this (COPD). This condition was refuted because it is associated with fewer symptoms the patient presents with. |
| Most likely diagnosis: | Gastroesophageal Reflux Disease (GERD): Patient presents with a backward flow of gastric contents, typically acidic, into the esophagus (Ball et al., 2015). Patient reports a burning, gnawing pain in the mid-epigastrium that worsens with recumbence (Baumann et al., 2016). GERD risk factors are obesity, pregnancy, smoking, eating large meals or eating late at night, eating certain foods (triggers), including fatty or fried meals, drinking particular beverages like alcohol or coffee, and taking certain medications, including aspirin (Mayo Foundation for Medical Education and Research, 2017). Based on the reported signs and symptoms from subjective and objective assessment, alcohol consumption, and recent changes in the patient’s medication, GERD is the primary diagnosis for the patient. Treatment / Management of GERD: The objectives of GERD management are to deal with symptom relief and avoid complications, including esophagitis, BE, and esophageal cancer. Changes in lifestyle, medical care with antacids and antisecretory drugs, surgical therapies, and endoluminal therapies are all possible forms of treatment. Lifestyle Modifications: The core component of any GERD treatment is thought to be lifestyle changes (Antunes et al., 2017). Given that underlying obesity is a substantial risk factor for the development of GERD and that studies have indicated that weight gain in people with a normal BMI has been linked to the onset of GERD symptoms, counseling about the significance of weight loss should be offered.Medical Therapy: Medical therapy is recommended if the patient does not respond to lifestyle changes. Antacids, antisecretory drugs such as histamine (H2) receptor antagonists (H2RAs) or PPI therapy, and prokinetic drugs make up medical treatment (Antunes et al., 2017). |
| References | Antunes, C., Aleem, A., & Curtis, S. A. (2017). Gastroesophageal reflux disease. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. Baumann, L. C., Dains, J. E., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note Malik, T. F., Gnanapandithan, K., & Singh, K. (2018). Peptic ulcer disease. Mayo Foundation for Medical Education and Research. (2017, November). Gastroesophageal reflux disease (GERD). Retrieved from https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940 Singh, A., Museedi, A. S., & Grossman, S. A. (2017). Acute coronary syndrome. Smith, R. E., & Shahjehan, R. D. (2020). Hiatal Hernia. In StatPearls [Internet]. StatPearls Publishing. The Cleveland Clinic Foundation. (2015, June). Non-Cardiac Chest Pain: GERD. Retrieved from https://my.clevelandclinic.org/health/diseases/15851-gerd-non-cardiac-chest-pain The Cleveland Clinic Foundation. (2017, July). Swallowing Problems: Achalasia. Retrieved from https://my.clevelandclinic.org/health/diseases/17534-swallowing-problems-achalasia/symptoms–diagnosis? |
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