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Gastroesophageal Reflux Disease Soap Note
Lorenys Puentes Martin
Miami Regional College
This study source was downloaded by 100000838493518 from CourseHero.com on 03-02-2022 10:21:49 GMT -06:00
https://www.coursehero.com/file/43461529/Soap-Note-GERDdoc/
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Gastroesophageal Reflux Disease Soap Note
Patient: Mr. T.P
Age: 83
Gender: F
Marital Status: Married
Race: Hispanic
Source: Patient
Subjective:
CC: "I have heartburn and abdominal pain."
HPI:: Patient reports pain to the midepigastric area. The pain began one day ago, is described as
burning, gnawing, rated as 7/10 at the onset, now 1-2/10. Pt relates that pain started after a large
meal, but not sure if the pain associated with a meal. No previous hx of abdominal pain. No
aggravating factors reported. Pain somewhat alleviated by the use of Ibuprofen and sleeping. No
pain radiation is reported. The patient reports positive anorexia — no change in BM. Pt is only
taking Ibuprofen, denies taking any other OTC meds. Patient denies recent trauma.
PMH:
Allergies: unknown
Childhood Illness: Chicken Pox
Adulthood illness: Diabetes Mellitus type 2
Surgical History: Cholecystectomy
Medication List:
- Metformin 500mg BID
FH: Mother – Hypertension and Myeloma Multiple.
This study source was downloaded by 100000838493518 from CourseHero.com on 03-02-2022 10:21:49 GMT -06:00
https://www.coursehero.com/file/43461529/Soap-Note-GERDdoc/
Gastroesophageal Reflux Disease Soap Note
Lorenys Puentes Martin
Miami Regional College
This study source was downloaded by 100000838493518 from CourseHero.com on 03-02-2022 10:21:49 GMT -06:00
https://www.coursehero.com/file/43461529/Soap-Note-GERDdoc/
, 2
Gastroesophageal Reflux Disease Soap Note
Patient: Mr. T.P
Age: 83
Gender: F
Marital Status: Married
Race: Hispanic
Source: Patient
Subjective:
CC: "I have heartburn and abdominal pain."
HPI:: Patient reports pain to the midepigastric area. The pain began one day ago, is described as
burning, gnawing, rated as 7/10 at the onset, now 1-2/10. Pt relates that pain started after a large
meal, but not sure if the pain associated with a meal. No previous hx of abdominal pain. No
aggravating factors reported. Pain somewhat alleviated by the use of Ibuprofen and sleeping. No
pain radiation is reported. The patient reports positive anorexia — no change in BM. Pt is only
taking Ibuprofen, denies taking any other OTC meds. Patient denies recent trauma.
PMH:
Allergies: unknown
Childhood Illness: Chicken Pox
Adulthood illness: Diabetes Mellitus type 2
Surgical History: Cholecystectomy
Medication List:
- Metformin 500mg BID
FH: Mother – Hypertension and Myeloma Multiple.
This study source was downloaded by 100000838493518 from CourseHero.com on 03-02-2022 10:21:49 GMT -06:00
https://www.coursehero.com/file/43461529/Soap-Note-GERDdoc/
