Sample Comprehensive SOAP Note
|Subjective||Name: Trevor ## DOB: 21/05/1968 Gender: Male Marital status: Divorced Accompanied by: None CC: “I have a recurrent heartburn and pain swallowing food.” 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.
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.
Current medication: None prescribed.
Allergies: denies having any food, drugs, or environmental allergies.
Social History: He divorced his wife five years ago and has been single since. The patient lives with his two sons and brother.
Family history Father- 87 years, Type II diabetes Mother- Died of a cardiac arrest at 65 years. Brother-30 years, Type II Diabetes. Sons- healthy
Review of Systems General: Denies fever and chills. Confirms appetite changes and weight gain.
Head, eyes, ears, nose, and throat: The patient has trouble swallowing but denies smell, vision, and hearing changes.
Integumentary: Denies any skin rashes, lesions, wounds, and changes.
Cardiovascular: The patient has chest pain.
Lungs: The patient has breathing difficulties.
Gastrointestinal: The patient has nausea and abdominal pain denies vomiting, constipation, diarrhea.
Genitourinary: Denies urinary frequency and difficulty in urination.
Peripheral vascular: Denies peripheral edema of all extremities.
Musculoskeletal: Denies any injury, joint, or muscle pain.
Neurological: Denies headaches, dizziness, confusion, or weakness. Endocrine: Denies endocrine issues
Skin– Denies any skin issues.
|Objective||Vitals: Height 5’9″ Weight 207 BMI 30.6, PR 89 BPM, Temp: 98.6 F, reports pain 2/10. Labs: Blood test results 128/75mmHg. |
Physical examination: Appearance: Well-groomed, no acute distress, cannot maintain a straight sitting position.
Cardiovascular- slightly faster heart rate, breath sounds present, and no murmur noted.
Respiratory- Breaths sounds present.
Gastrointestinal- No hernia observed; the abdomen is hard.
Speech: Spontaneous, appropriate rate, appropriate tone, and low volume without pressured speech, with some problems expressing selfEye contact: IntermittentMotor Activity: Has trouble with movement.
Affect: Full, even, and congruent with mood Mood: “Good” Behavior: Cooperative and conversant
|Assessment||Diagnosis Hypertension I10 Obesity E66.9 Gastroesophageal reflux disease K21.9 Differential Diagnosis Gastroesophageal reflux disease K21.9 Peptic Ulcer disease K27.2 Gastritis K29.70 Coronary Artery Atherosclerosis I25.10 The patient’s health has declined based on his medical records. |
Final Assessment The 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.
Nonetheless, 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). Some 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. Nonetheless, 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.
Treatment Goals Gastroesophageal reflux disease K21.9- reduce symptoms prevent relapse and esophagitis complications (Lim et al., 2018).Hypertension I10- BP of <130/80mmHg to avoid the risk of cardiovascular disease.
Obesity E66.9- Adopt a healthy lifestyle to avoid excessive weight gain.
The patient seems to understand the importance of medication prescribed and is willing to adhere to the treatment plan, unlike the last visit.
Also reviewed the potential benefits and risks for PPIs and alternatives to treatment.
|Plan||Therapeutics Pharmacological Prescribe 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. Non-pharmacological Weight loss Engage in regular physical activity- aerobics for 90-150 minutes per week Take small frequent meals and increase potassium intake. |
Reduce sodium intake. Avoid smoking Education Educate the patient on the need to adhere to the medication prescribed. Provide dietary information. Guide 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. Educate the patient on the symptoms he should look for, indicating the need for urgent care. Educate the patient on the risk factors of gastroesophageal reflux and hypertension alongside the disease symptoms to help prevent adverse outcomes.
Ensure the patient is aware of the complications associated with hypertension, including stroke and heart attack. Collaboration/Consultation Consult a dietician to help develop a meal plan to help the patient lose excess weight.
Follow up Evaluation with a provider in one week to review the blood pressure levels. Visit the clinic in case symptoms are not relieved.
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Lim, 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
Savarino, 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
Savarino, 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
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