NU 518 Comprehensive SOAP Note, Exams of Nursing

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Comprehensive SOAP Note

July 10th, 2019 @ 1030 AM

Patient Information : CJ is a pleasant, 27-year-old married, Caucasian male currently residing in Andalusia, Alabama. Insured by Blue Cross and Blue Shield of Alabama. Referral & Reliability : Self-referred and seems reliable.

S – Subjective Data

Chief Complaint : “I keep having heartburn after eating.”

HPI:

• Location – Upper stomach, chest, and throat. Pain does not radiate.
• Quality – “Burning sensation.”
• Quantity/Severity – Discomfort from burning sensation is 4 on 0-10 pain scale.
• Timing – Sudden onset 2 weeks ago after eating Mexican food; reoccurring episodes 2- times weekly since initial episode after eating spicy or greasy foods; can last 2 hours or longer.
• Setting/Context – Patient believes “spicy Mexican food irritated his stomach triggering heartburn.”
• Aggravating or Relieving Factors – Spicy or greasy food, drinking soft drinks, and using smokeless tobacco worsen symptoms. Taking OTC Tums helps relieve symptoms.
• Self-Treatment – OTC Tums 750 mg, 2 tabs by mouth at the onset of symptoms; some relief after about 2 hours after taking Tums
• Past Medical, Family, or Social History related to CC/HP – Patient consumes fast food almost daily, drinks 3-4 caffeinated beverages daily, and uses 1 can smokeless tobacco daily. No pertinent family Hx assessed.

PMHx:

• Childhood Illnesses – Chickenpox (1997). Denies other childhood illnesses.
• Major Adult Illnesses – Migraines (onset 2008) Controlled with medication – see listed below; idiopathic elevated liver enzymes (onset 2018). Denies other adult illnesses.
• Immunizations – Immunizations are “up to date from previous employment overseas.” Tdap 2018; HBV 2018; Pneumonia 2018; Influenza 2018; Polio 2018; Pertussis 2016; Diphtheria 2018; MMR 2018; Denies having HPV vac.
• Health Maintenance Screenings – TB skin test 2018, stool for occult blood 2018, eye exam 2018, hearing test 2018, prostate exam 2018, cholesterol screening 2018, hepatic panel 2018

• Hospitalizations/Surgeries

o 2014 observation admit for “separated clavicle from a snowboarding accident.”

o 2011 observation admit for “arm injury from wakeboarding accident.” o 2009 surgical admit for “ACL repair of the left knee.”

- Injuries/Accidents – See above. Denies other injuries/accidents.

Personal/SocHx:

- Family Structure – Born in Mobile, Alabama. Lives with wife and daughter. Monogamous relationship with wife for 8 years. Large family and friend support system available. - Educational Level – Some college. - Occupational history/Hobbies – Floor Hand offshore oilrig 2011-2018, Finance Manager at car dealership 2018-present. Enjoys spending time with family. - Economic status – “Middle-class.” Self-sufficient with patient and wife’s combined salaries. No financial concerns. - Home conditions/Environment – No current concerns for exposure to toxins or allergens at home or work. Has history has previous exposure to toxins and allergens on offshore oil rig. - Spiritual/Cultural Preferences – “Christian, Southern-Baptist” - Tobacco Use – 1 can smokeless tobacco per day - Recreational Drugs – Denies use - Alcohol – Denies use - Caffeine – Drinks 3-4 Dr. Pepper soft drinks daily - Sleep – Consistent sleep-wake cycle. Averages 7 hours of sleep per night. - Safety Measures – Denies use of sunblock or seatbelt. Home has smoke detectors

• Diet (24-hour recall)

o Breakfast – bacon biscuit and Dr. Pepper o Lunch – chicken nuggets and Dr. Pepper o Dinner – Beef rice, green beans, and Dr. Pepper

- Exercise – “Walks 2-3 times weekly, performs chores around home, and plays with daughter.”

ROS:

- General – Reports normal weight of 160 lbs. Has had 10 lb. Weight gain over the last 9 months due to job change with less physical demands. Denies weakness, fatigue, or fever. - Skin – Denies rashes, lumps, sores, itching, dryness, change in color, changes in hair or nails, or changes in size or color of moles.

• HEENT

o Head – Reports Hx of migraines, denies any currently. No recent head injury, dizziness or lightheadedness. o Eyes – Last eye exam in 2018. Denies glasses or contacts, pain, redness, excessive tearing, spots, specks, flashing lights, cataracts, or glaucoma. Reports blurred vision with migraines – none currently. o Ears – Last hearing test 2018. Patient denies tinnitus, vertigo, earaches, infection, drainage, or loss of hearing. o Nose/Sinuses – Denies frequent colds, nasal stuffiness, discharge, itching, hay fever, nose bleeds, or sinus trouble.

• Hematologic – Denies anemia, easy bruising or bleeding, and past transfusions.

• Endocrine – Denies “thyroid trouble” or diabetes. Denies heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, or changes in glove or shoe size.

O – Objective Data

PE:

- General Survey – Alert and oriented 27-year-old male. Pleasant and cooperative. Sitting in relaxed position with comfortable eye contact. Well-groomed and dressed appropriately for age and season. Does not appear to be in any acute distress. - Vital Signs – BP: 127/60, P: 80, R:16, Temp: 98.6 oral, Weight: 170 lbs., Height: 5’9, BMI 25. - Skin – Warm and dry. No redness, wounds, lesions, or abnormal moles assessed. Color appropriate for ethnicity.

• HEENT

o Head and Face – Normocephalic/atraumatic. No lesions or moles assessed on scalp or face. No balding assessed. Scalp and hair are clean. Hair texture is thick. o Eyes - Pupils 3 mm bilaterally. PERRLA bilaterally. EOM’s and visual fields intact. Conjunctiva pink; sclera white with no icterus noted. o Ears – No loss of hearing assessed with whisper test. Auricles, canals, and drums normal bilaterally. o Nose/Sinuses – No septal deviation assessed. No nasal drainage or evidence of epistaxis. Mucosa pink. No sinus tenderness assessed. o Mouth/Throat – Lips hydrated, no fissures noted; oral mucosa moist with pallor noted to gums; normal dentation; no tooth decay; gingival margin intact; labial frenulum intact; tongue strength appropriate and symmetric; soft palate rises; uvula is midline, positive gag reflex; tonsils appropriate in size and shape. No difficulties swallowing.

- Neck – Supple. No unusual pulsations in neck. Trachea midline. No goiter assessed. No swelling/tenderness to cervical nodes. - Back – Spine erect and midline; appropriate flexion, rotation, and ROM noted to spine. Shoulder height symmetrical. No pain or tenderness assessed. - Breasts – No swelling/tenderness assessed to axillary or epitrochlear nodes. - Thorax/Lungs – Chest symmetrical. No masses or deviations noted on inspection, palpation or percussion; normal effort with WOB; no SOB; lung sounds clear throughout on auscultation; no cough noted. - Cardiovascular/Peripheral Vascular/ (CV/PV): PMI visualized and palpable at 5th intercostal space, medial to left MCL, rate 80 bpm and regular. No JVD or bruits. Normal S1 and S2 heard on auscultation of valves; No S3 or S4 heard. No lifts or heaves assessed. Radial, brachial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses

- Abdomen – Soft, slightly rounded, nontender. No tenderness or masses assessed with inspection, percussion, or palpitation. Bowel sounds present and normoactive x quadrants. No bruits assessed. Liver borders are palpable and smooth; liver span 8 cm. Spleen unpalpable. No CVA tenderness bilaterally. - Musculoskeletal System – No deformities or enlarged joints. Spine, legs, and feet are aligned. No altered gait or balance assessed. 5+ normal muscle strength. ROM good in all extremities. - Genitalia/Rectum – No hernias present. No lesions or sores present on penis. No penile discharge assessed. No scrotal swelling or edema present. - Nervous System – Alert and oriented to person, place, time, and situation. Judgment, abstract reasoning, mood, and ability to calculate appropriate and intact. Immediate, recent, and remote memory is intact. Cranial Nerves I – XII grossly intact. RAMs are rapid, smooth, and symmetric. No pass-pointing assessed with point-to-point movements. Gait is steady and fluid. No loss of balance assessed. Romberg test negative. Brachioradialis, bicep, tricep, patellar, and achilles reflexes 2+ bilaterally. Plantar response noted. Babinski reflex negative. No ankle clonus present. Sensory to touch is grossly intact. Stereognosis, graphesthesia, and proprioception intact.

Differential Diagnosis:

1. Gastroesophageal reflux disease (GERD) 2. Hiatal hernia 3. Gastritis 4. Peptic ulcer disease 5. Stomach (Gastric) cancer 6. Food allergy

A – Assessment Working diagnosis:

1. GERD – Heartburn, indigestion and excessive belching are highly indicative of GERD and are reasons to rule in GERD as the cause of patient’s health problem (McQuaid, 2019). These classic symptoms are triggered by overproduction of stomach acid. The patient has had a 10 lb., has an unhealthy diet, and uses smokeless tobacco, which tends to increase gastric acid production (McQuaid, 2019; Mayo Clinic, 2018). 2. Hiatal Hernia - Acid moving up into esophagus causing throat pain is reason to possibly rule in hiatal hernia since the chief significance of hiatal hernias is the tendency of affected individuals to have GERD (McQuaid, 2019; Kahrilas & Hirano, n.d.). 3. Gastritis – Patient denies nausea, vomiting, anorexia, and hematemesis, which are symptoms of erosive gastritis, and therefore, a reason to rule out this diagnosis (McQuaid, 2019). 4. Peptic Ulcer Disease (PUD) – Patient has abdominal, chest, and throat pain. Since pain is not “well localized to epigastrium” as common with PUD and he denies common

symptoms of PUD, including nausea, vomiting, anorexia, and weight loss, this diagnosis can likely be ruled out (McQuaid, 2019; Peptic Ulcer Disease, 2019).

5. Stomach (Gastric) Cancer – Patient denies common symptoms of gastric cancer, including changes in appetite, nausea, vomiting, weight loss, and blood in stools. Also, no abdominal tenderness or masses assessed with palpation – findings typical of gastric cancer. Therefore, this diagnosis can likely be ruled out (Smith, 2019). 6. Food Allergy - Dairy products, eggs, nuts, and shellfish are the most commonly implicated foods in food allergies. Common symptoms include swelling and itching of the lips, mouth, and pharynx; nausea; abdominal cramps; vomiting; and diarrhea. Since patient’s indigestion is only made worse by spicy/greasy foods, and he denies above symptoms, food allergy can likely be ruled out (Rowe & Gaeta, 2016).

P – Plan

Working Diagnosis:

• GERD

1. Encourage lifestyle modifications such as eating smaller meals, decreasing caffeine intake, and stopping use of smokeless tobacco. Encourage a healthy diet by eliminating spicy/greasy foods from diet (patient provided with written education). Large meals, spicy/greasy foods, caffeine, and tobacco use can increase gastric acid content (GERD, 2019; McQuaid, 2019). 2. Increase OTC Tums dosage to 1000mg 2 tabs PO every 4 hours PRN heartburn to neutralize the gastric acid. If no relief in 24 hours, start OTC Zantac 150mg PO BID to decrease gastric acid production. Instruct patient taking antacids before meals may reduce symptoms. Encourage patient to keep diary of pain symptoms, relation to meals and activity, and associated symptoms (McQuaid, 2019; Smith, 2018). 3. Follow up in 2 weeks to re-evaluate. For unresolved symptoms of GERD, begin once-daily PPI (Omeprazole 20mg PO daily); side effects of Omeprazole such as headache, diarrhea, and abdominal pain discussed with patient (GERD, 2019; McQuaid, 2019). 4. Re-evaluate in 4 weeks. For continued or unresolved symptoms, will consider performing abdominal ultrasound to rule in or rule out hiatal hernia. Will increase Omeprazole dosage to 40mg PO daily (McQuaid, 2019; Kahrilas & Hirano, n.d.). 5. If reoccurrence in <3 months, will consider testing for H. Pylori and referring to gastroenterologist for EGD/or endoscopy, which can be used to rule out other conditions that may be causing GERD symptoms (Mayo Clinic, 2018; GERD, 2019; McQuaid, 2019).

Unhealthy Diet

Substance Abuse (smokeless tobacco)

Weight gain

References

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking (12th).

Philadelphia, PA: Wolters Kluwer.

Gastroesophageal Reflux Disease (GERD). (2019). In: Papadakis MA, McPhee SJ, Bernstein J. eds.

Quick Medical Diagnosis & Treatment 2019 New York, NY: McGraw-Hill.

Retrieved from http://accessmedicine.mhmedical.com.libproxy.usouthal.

edu/content.aspx?bookid=2566&sectionid=206884254.

Kahrilas, P. J. & Hirano, I. (n.d.) Diseases of the esophagus. In: Jameson J, Fauci AS, Kasper

DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine,

20e New York, NY: McGraw-Hill. Retrieved from http://accessmedicine.

mhmedical.com.libproxy.usouthal.edu/content.aspx?bookid=2129&sectionid=

Mayo Clinic. (09, March 2018). Gastroesophageal reflux disease (GERD). Retrieved from

https://www.mayoclinic.org/diseases-conditions/gerd/diagnosis-treatment/drc-

McQuaid, K. R. (2019). Gastrointestinal disorders. In M. Papadakis & S. McPhee (Eds.),

Current medical diagnosis and treatment (pp. 618-623). Retrieved from

https://accessmedicine-mhmedical-com.libproxy.usouthal.edu/content.aspx?bookid=

&sectionid=194439115#

Peptic Ulcer Disease. (2019). In: Papadakis MA, McPhee SJ, Bernstein J. eds. Quick Medical

Diagnosis & Treatment 2019 New York, NY: McGraw-Hill. Retrieved from

http://accessmedicine.mhmedical.com.libproxy.usouthal.edu/content.aspx?

bookid=2566&sectionid=206891861.

Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill. Retrieved from

http://accessmedicine.mhmedical.com.libproxy.usouthal.edu/content.aspx?

bookid=1658&sectionid=109385103.

Smith, H. (2018). Heartburn, gastro-oesophageal reflux disease and non-erosive reflux disease.

Professional Nursing Today, 22(4), 25–30. Retrieved from http://creativecommons.org/

licenses/by-nc-nd/4.

Smith, M. A. (2019). Gastric cancer. In: Usatine RP, Smith MA, Mayeaux, Jr. EJ, Chumley HS.

eds. The Color Atlas and Synopsis of Family Medicine, 3e New York, NY: McGraw-Hill.

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usouthal.edu/content.aspx?bookid=2547&sectionid=206780086.