Diagnosis and management of EENT and URIs Week 2.1

GASTROESOPHAGEAL REFLUX DISEASE SOAP
NOTE
NUR HEALTH ASS Gastroesophageal Reflux Disease Soap Note
graded A




Gastroesophageal Reflux Disease Soap Note

Lorenys Puentes Martin

Miami Regional College




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https://www.coursehero.com/file/43461529/Soap-Note-GERDdoc/

, GASTROESOPHAGEAL REFLUX DISEASE SOAP
NOTE
NUR HEALTH ASS Gastroesophageal Reflux Disease Soap Note
graded A

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 100000832558064 from CourseHero.com on 03-04-2022 01:21:28 GMT -06:00


https://www.coursehero.com/file/43461529/Soap-Note-GERDdoc/