CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes Student Name: Course: Patient Name: B.N. Date: Time: Ethnicity: Caucasian Age: 41 Sex: Male SUBJECTIVE (must complete this section) CC: “I have a heartburn and acid reflux that keeps waking me up at night” HPI: B.N. is a 45-year-old male patient with a history of gradually worsening gastroesophageal reflux symptoms. He presents with frequent typical episodes of heartburn following spicy or fatty meals and periodic regurgitation of sour-smelling fluid into his mouth. Onset was 3 months ago and have gradually worsened. Located in the epigastric region, with occasional radiation to the throat with a duration typically last 1–2 hours after meals or when lying down at night, with a character: A burning pain or pressure in the chest and upper abdomen. The aggravating factors have been consuming spicy, fatty, or acidic foods, as well as when bending over or lying flat and the relieving factors the use of over-the-counter antacids. Timing have been intermittently throughout the day but are most frequent post-meals and during nighttime, with a Severity of 6/10 on average, with occasional exacerbations to 8/10 during severe episodes. · Medications: Omeprazole 20 mg daily (started 2 weeks ago) · Previous Medical History: Hypertension (diagnosed 4 years ago) and GERD. Allergies: Penicillin , with dizziness and flushing sensation. Medication Intolerances: None reported Chronic Illnesses/Major traumas: Hypertension Hospitalizations/Surgeries: None reported FAMILY HISTORY · M: Alive and healthy · MGM: Late, asthma · MGF: Alive, GERD · F: Alive, obesity · PGM: died of road accident · PGF: Alive, healthy Social History: B.N. is an office employee with a 14-year history of reported cigarette smoking. He smokes a half pack per day and sporadic alcohol use, having two or more beers per week. He denies all illicit drug use. His food intake is fast food and coffee drinking, frequent enough to explain his gastrointestinal complaints. His habits of smoking and eating are addressed as possible aggravating factors in his illness. REVIEW OF SYSTEMS General: B.N is weight loss due to acid reflux during meals. Cardiovascular: No chest pain, palpitations, or edema Skin: No rashes, lesions, or itching Respiratory: No cough, shortness of breath, or wheezing Eyes: No reported vision changes, denies eye pain. Gastrointestinal: Heartburn, regurgitation, denies vomiting, diarrhea, or constipation Ears: No hearing loss, tinnitus, or ear pain Genitourinary/Gynecological: No urinary symptoms Nose/Mouth/Throat: No nasal congestion, or dental issues, sore throat due to acid reflux. Musculoskeletal: No joint pain, no falls. Breast: Denies any change. Neurological: No headaches, dizziness, or numbness Heme/Lymph/Endo: Denies anemia or any endocrine disorder. Psychiatric: Denies anxiety, or mood changes. OBJECTIVE (Document PERTINENT systems only. Minimum 3) Weight: 180lbs Height: 5’9” BMI: 25.9 BP:138/88mmHg Temp: 99.2°F Pulse: 78bpm Resp:16/min General Appearance: Well-nourished, alert, and oriented x3. Appears comfortable. Skin: Smooth with no rashes, moles, red spots HEENT: Normocephalic, PERRLA, oral mucosa pink Read More …