NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note
NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
Week Seven: Assessment of Abdomen and Gastrointestinal System
Review of case study #2
Scenario: A 50-year-old male complains of burning pain starting at the abdomen and rising to the middle of his chest. He describes the pain as a gnawing feeling that begins after meals, especially when lying down.
Episodic/Focused SOAP Note for Throat Exam
Patient Information: V.S.     Age: 50 y.o.        Sex: Male          DOB: 8/7/1967
S.
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Chief Complaint/Reason for Visit:
The patient reported abdominal discomfort for the past two days that feels like “burning sensation in his chest.”
History of Present Illness:
Mr. V.S. is a 50 y/o Caucasian male with h/o hyperlipidemia, hypothyroidism, hypertension, DM Type II, presenting with c/o abdominal discomfort ranging from 5 to 6 out of 10 for two days. According to the patient, his stomach discomfort has however been ongoing for the past two days and describes it as burning pain starting at the mid-abdomen and rising to the middle of his chest. He reported that the pain usually begins when he eats and worsens when lying down but subsides when he walks. Patient denies constipation or diarrhea. His last meal was at 14:00 today. According to the patient, he recently started taking aspirin once a day as advised by his primary care physician. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note
Current Medications:
Atorvastatin (Lipitor) 40 mg tablet Take 40 mg nightly
Levothyroxine (SYNTHROID) 100 mcg once daily
Metformin (GLUCOPHAGE) 500 mg tablet two times daily (with breakfast & dinner)
Aspirin 81mg once daily
Allergies: No known allergies
PMHx:

Diabetes mellitus (managed by diet and medication)
Diabetes type 2, controlled with diet and medication
Hyperlipidemia (currently on medication)
Hypothyroidism (managed by medication)

Fam Hx: Reported both parents are alive, father with hypertension, mother with diabetes.
Personal/Social History: Drinks ETOH occasionally. Consumes 2-3 cans of beer two times per week. Denies smoking, and illicit drug use.
Review of Systems:
Constitutional:  A&O x4, pleasant and cooperative. Reports abdominal pain 5-6/10. No acute distress. Denies weight loss, weakness, or fatigue.
HEENT:  Denies headache, sore throat or changes in hearing.
SKIN:  No rash or itching.
CARDIOVASCULAR:  Reported burning sensation on his chest when lying down.
RESPIRATORY:  Denies shortness of breath or cough.
GASTROINTESTINAL:  Reported abdominal discomfort for the past two days ranging from 5-6/10. Described as “gnawing” and “burning.” Denies nausea or vomiting. No change in bowel pattern.
GENITOURINARY:  Denies dysuria or hematuria.
NEUROLOGICAL:  Denies focal loss of strength or loss of sensation.
MUSCULOSKELETAL:  Denies focal weakness, facial droop, or joint swelling.
HEMATOLOGIC:  No anemia, bleeding or bruising. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note
LYMPHATICS:  No enlarged nodes. No cervical lymphadenopathy
ALL OTHER SYSTEMS REVIEWED AND NEGATIVE OF PERTINENT FINDINGS
O.
Physical exam: Vital signs: B/P 117/59, Pulse 108 (strong and regular); Temp 98.3F orally; RR 18; non-labored; SpO2: 96% room air;
Height 1.575 m (5′ 2″), weight 73.5 kg (162 lb),
General: A&O x4, pleasant and cooperative. Not in any acute distress.
HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.
Neck: Supple. No JVD. Trachea midline. No pain, swelling or palpable nodules.
Chest/Lungs: Clear to auscultation bilaterally. No wheezing, crackles or rhonchi. No accessory muscle use.
Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.  NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note
ABD: Reports of 5-6/10 pain. Soft, nontender, nondistended. Hyperactive BS. No palpable hepatosplenomegaly
Genital/Rectal: continent of bladder and bowel.
Musculoskeletal: Normal range of motion. Regular muscle mass for age. No swelling or joint deformities.
Neuro: Alert and oriented x4. Strength and sensation intact.
Skin/Lymph Nodes: No cervical lymphadenopathy. No rashes, or erythema. No lesions. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note
Diagnostic results:
EKG: NSR
Laboratory studies:
CBC – WBC 9.4; H/H: 14.3/41.0; PLT: 289.
Chemistry Panel: BUN/Crea: 19/0.52; Glucose: 117*

Pylori serology: negative

Esophageal pH Test: pending
NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note
 
A.
Differential Diagnoses (DD):

Gastroesophageal Reflux Disease (GERD): backward flow of gastric contents, which are typically acidic, into the esophagus (Ball, Dains, Flynn, Solomon, & Stewart, 2015, p. 400).

–    Patient with reports of burning, gnawing pain in the mid-epigastrium that worsens with recumbency (Baumann, Dains, & Scheibel, 2016, p. 27).
–    Risk factors for GERD include obesity, pregnancy, smoking, eating large meals or eating late at night, eating certain foods (triggers) such as fatty or fried foods, drinking certain beverages such as alcohol or coffee, taking certain medications, such as aspirin (Mayo Foundation for Medical Education and Research, 2017).
–    Due to the reported symptoms, alcohol consumption, and recent changes in the patient’s medication, GERD is the primary diagnosis for the patient. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

Acute coronary syndrome: may have heartburn or a bitter taste in the mouth due to stomach fluid “coming up” which usually occurs after eating and gastroesophageal reflux disease (GERD) is the most common cause of non-cardiac chest pain (The Cleveland Clinic Foundation, 2015).
Peptic Ulcer: associated with reports of burning or gnawing pain that occurs most often with an empty stomach, stress, and alcohol intake which is relieved with food intake (Baumann, Dains, & Scheibel, 2016, p. 27).
Achalasia: a condition where the esophagus is unable to move food into the stomach as the lower esophageal sphincter stays closed during swallowing, back up of food results and symptoms include vomiting undigested food, chest pain, heartburn and weight loss (The Cleveland Clinic Foundation, 2017).
Gastritis: is a constant burning pain in the epigastric area that can be accompanied by nausea, vomiting, diarrhea, or fever and alcohol, nonsteroidal inflammatory drugs and salicylates make the pain worse (Baumann, Dains, & Scheibel, 2016, p. 27).
Hiatal Hernia with esophagitis: is a condition where part of the stomach passes through the esophageal hiatus in the diaphragm and into the chest cavity with symptoms of epigastric pain or heartburn that worsens with lying down and is resolved by sitting up or antacids (Ball, Dains, Flynn, Solomon, & Stewart, 2015, p. 401).

 
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Baumann, L. C., Dains, J. E., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note
Mayo Foundation for Medical Education and Research. (2017, November). Gastroesophageal reflux disease (GERD). Retrieved from https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940
The Cleveland Clinic Foundation. (2015, June). Non-Cardiac Chest Pain: GERD. Retrieved from https://my.clevelandclinic.org/health/diseases/15851-gerd-non-cardiac-chest-pain
The Cleveland Clinic Foundation. (2017, July). Swallowing Problems: Achalasia. Retrieved from https://my.clevelandclinic.org/health/diseases/17534-swallowing-problems-achalasia/symptoms–diagnosis?view=print NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

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