SOAP Note
Patient Initials: S.P. Age: 42 Gender: Female
SUBJECTIVE DATA
Chief Complaint (CC): "I've been having stomach discomfort and problems for the past few weeks."
History of Present Illness (HPI): 42-year-old Caucasian female presents with complaints of stomach discomfort for the last 3-4 weeks.
Location: Upper abdominal region
Quality: Burning sensation
Quantity or severity: Moderate to severe
Timing: Began gradually about 3-4 weeks ago and has been persistent since then
Setting: Symptoms worsen post meals
Factors: Spicy foods seem to exacerbate discomfort, no relief noted with over-the-counter antacids
Associated manifestations: Reports occasional nausea, bloating, and belching
Medications: OTC antacids as needed
Allergies: No known drug allergies
Past Medical History (PMH): Hypertension, Childhood Measles
Past Surgical History (PSH): Tonsillectomy at age 7
Sexual/Reproductive History: G2P2, Menarche at age 12, regular menstrual cycles, uses birth control pills
Personal/Social History: Non-smoker, occasional alcohol use (1-2 glasses of wine/week), no illicit drug use. Works as an accountant, mostly sedentary lifestyle.
Immunization History: Flu shot last year, Tdap 10 years ago
Significant Family History: Father had peptic ulcer disease, mother has hypertension
Lifestyle: Lives with husband and two children, has a moderate level of stress due to work, has a support system in place
Review of Systems
General: No recent weight changes, no fatigue
HEENT: Normal, no issues
Respiratory: Clear, no shortness of breath or cough
Cardiovascular/Peripheral Vascular: Regular rhythm
Gastrointestinal: As described in HPI
Genitourinary: Normal, no complaints
Musculoskeletal: No joint or muscle pains
Psychiatric: No anxiety, depression, or other psychiatric symptoms
Neurological: Alert, oriented x3
Skin: No rashes, sores, or other abnormalities
OBJECTIVE DATA
Physical Exam
Vital signs: BP 130/85, HR 75, RR 16, Temp 98.6F, Weight 150lbs, BMI 24
General: Well-groomed, alert, oriented, in no distress
HEENT: PERRL, EOMI, no oropharyngeal erythema or exudate
Chest/Lungs: Clear to auscultation bilaterally
Heart/Peripheral Vascular: S1 and S2 normal, no murmurs, regular rhythm, peripheral pulses intact
Abdomen: Soft, non-tender, non-distended, positive bowel sounds, mild tenderness in the epigastric region
Genital/Rectal: Deferred
Musculoskeletal: Full range of motion, no pain or swelling
Neurological: Alert, cranial nerves II-XII intact, no focal deficits
Skin: Warm, dry, no rashes
ASSESSMENT
The primary diagnosis for this patient is H. pylori gastritis, which is supported by a positive stool sample indicating H. pylori presence (Goud et al., 2019). Guidelines emphasize the importance of testing in patients manifesting chronic gastritis symptoms (Shah et al., 2021).
Differential diagnoses include:
1. Gastroesophageal reflux disease (GERD): Given the patient's presentation with a burning sensation, bloating, and belching, GERD is a plausible diagnosis (Wilkinson et al., 2019). GERD is typically a common consideration in the context of upper gastrointestinal symptoms.
2. Peptic ulcer disease (PUD): Given her family history and epigastric pain, PUD remains a possibility (Alzharani et al., 2020). An endoscopic examination might offer insights into the presence of any ulcers, further delineating the diagnosis.
3. H. pylori gastritis: The patient's symptoms, and what could be described as chronic episodes, combined with the lab results, could also justify this diagnosis (Hall & Appelman, 2019).
In addition to the present complaints, it would be important to account for her previous diagnosis of...
…eradication, for example, would be effective from a clinical standpoint, but it does come with potential side effectsso this is something that would have to be talked about with the patient absolutely. Taking additional time to go into these potential side effects is helpful for the doctor-patient relationship because then the patient fully understands them, and it gives them an opportunity to voice their concerns, which is something that ought to be prioritized in future encounters. This would help with adherence to treatment, in my opinion, and also in building trust and establishing a solid relationship with the patient.The experience also reinforced the necessity of evidence-based medicine in clinical practice. My preceptor's commitment to an evidence-driven approach has been, as always, a good reminder of its value. Evidence directs us so that our decisions are rooted in the best available information, and so that we are offering the highest standard of care. It is an approach that seamlessly ties into a holistic model of patient care, where the patient is viewed as a person and not just as a set of symptoms. Every patient is a unique individual with their own needs, experiences, and background of family health. This is a holistic perspective, which is something that has been emphasized throughout, and it reiterates the imperative of treating not just the disease, but the individual as a whole. I am certain that keeping this…
References
Alzahrani, M. A., Alfageeh, K., Thabet, T., Ali, N., Alnahdi, N., Mohammed, M., ... &Alsamghan, A. S. (2020) Assessment of Health-Related Knowledge and Practices among Patients with Peptic Ulcer. Middle East Journal of Family Medicine, 7(10), 33.
Georgopoulos, S., & Papastergiou, V. (2021). An update on current and advancingpharmacotherapy options for the treatment of H. pylori infection. Expert Opinion on Pharmacotherapy, 22(6), 729-741.
Goud, E. S. S., Kannan, R., Rao, U. K., Joshua, E., Tavaraja, R., & Jain, Y. (2019). Identificationof Helicobacter pylori in saliva of patients with and without gastritis by polymerase chain reaction. Journal of pharmacy & bioallied sciences, 11(Suppl 3), S523.
Hall, S. N., & Appelman, H. D. (2019). Autoimmune gastritis. Archives of pathology &laboratory medicine, 143(11), 1327-1331.
Liguori, G., & American College of Sports Medicine. (2020). ACSM's guidelines for exercisetesting and prescription. Lippincott Williams & Wilkins.
Shah, S. C., Piazuelo, M. B., Kuipers, E. J., & Li, D. (2021). AGA clinical practice update on thediagnosis and management of atrophic gastritis: expert review. Gastroenterology, 161(4), 1325-1332.
Wilkinson, J. M., Cozine, E. W., & Loftus, C. G. (2019). Gas, bloating, and belching: approachto evaluation and management. American family physician, 99(5), 301-309.
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