Week 10 SOAP note- Gastroesophageal Reflux Disease

Week 10 SOAP note- Gastroesophageal Reflux Disease

Week 10 SOAP note- Gastroesophageal Reflux Disease

Patient Initials: ___AL____               Age: ___9 Week____                         Gender: ___F____

SUBJECTIVE DATA:

Chief Complaint (CC):  Episodes of spitting up that have worsened, weight recheck

History of Present Illness (HPI):  Patient is premature, African American infant born 6 weeks early. Patient was vaginal delivery. Mother did not have problems during pregnancy. Patient seen 1 week ago for weight check due to prematurity. Mother stated at that time that patient was taking 60ml of Neosure formula every 2-3 hours but was spitting up a “good bit” of formula. Per mother, formula was coming out infant’s nose, causing infant to cry. Mother states that spit up does not appear to be curdled. Mainly occurs at night. Infant was switched to anti- reflux formula and told to come back today for weight check. Mother states that infant appears to be vomiting more but is still taking 60ml of formula every 2-3 hours. Infant has gained only 2 ounces over last week.

 

Medications: none

Allergies: NKDA

Past Medical History (PMH): Preterm birth at 32 weeks gestation.

Past Surgical History (PSH):  none

Sexual/Reproductive History: No sexual behavior. Patient is infant.

Personal/Social History: Mother denies alcohol, tobacco, or drug use during pregnancy. Patient sleeps well. Patient drinks Neosure formula. Mother denies smoking in home.

Immunization History: Patient received HiB vaccination at discharge from hospital after birth. Mother refused patient’s 2-month vaccinations due to personal beliefs.

Significant Family History: 

Lifestyle: …

Review of Systems:

General: 

HEENT: 

Neck: 

Breasts: 

Respiratory: 

Cardiovascular/Peripheral Vascular: Denies any swelling in extremities.

Gastrointestinal: 

Genitourinary: Denies trouble with urination.

Musculoskeletal: 

Psychiatric: 

Neurological: 

Skin:   

           Hematologic: 

Endocrine: 

Allergic/Immunologic: 

 

OBJECTIVE DATA:

Physical Exam:

Vital signs: Temperature 97.7 rectal, heart rate 152, respiratory rate 34, oxygen saturation 100% ra. Wt: 7.7lbs, ht: 19in. BMI 15

General: Patient is well appearing African American female infant. She is sleeping in mother’s arms, while mother is sitting in chair in room. She is alert during examination. Patient appears to be well taken care of, with clean clothes and diaper on.

HEENT: 

Neck: 

Chest: 

Lungs: 

Heart/Peripheral Vascular: 

 Abdomen: 

Genital/Rectal: Did not assess. Mother denies any pain or problems.

Musculoskeletal: 

Neurological: did not assess.

Skin: Skin is warm and dry to touch. Skin is intact. No rashes or lesions present

Labs: …

 

ASSESSMENT:

Diagnosis – Gastroesophageal Reflux (GERD)- …

 

1) Gastroenteritis – …

2) Pyloric Stenosis- …

3) Failure to Thrive- …

 

PLAN:

Treatment Plan:  …

Health Promotion: …

Disease Prevention:  …

REFLECTION:  I learned a great deal from caring for this patient. I learned that premature infants can be very different to take care of versus a normal, healthy infant. The concern for this patient is that her regurgitation had worsened with the anti reflux formula that was tried for 1 week. Usually patients have improvement with this type of formula.  The other concern was of weight gain since she was premature. The patient was sent for an abdominal ultrasound that evening to rule out potential pyloric stenosis. I learned that the presentation of pyloric stenosis may be delayed in premature infants (Constanzo, Vincour, & Berman, 2017).  This case also taught me about educating parents. The mother was a first-time mother. She had personal beliefs regarding immunizations, which the provider acknowledged and educated her about.

________________________

Preceptor Signature and Date

References:

Bentley, J.P., Simpson, J., Bowen, J., Morris, J., Roberts, C.L., & Nassar, N. (2016). Gestational age, mode of birth, and breastmilk feeding all influence acute early childhood gastroenteritis: a record- linkage cohort study. BioMed Central Pediatrics, 16 (55). DOI: 10.1186/s12887-016-0591-0.

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L.  (Eds.). (2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier.

Constanzo, C., Vincour, C., & Berman, L. (2017). Prematurity affects age of presentation of pyloric stenosis. Clinical Pediatrics, 56 (2). DOI: 10.1177/0009922816641367

Rybak, A., Pesce, M., Thapar, N., &Borrelli, O. (2017). Gastro-esophageal reflux in children. International Journal of Molecular Sciences, 18 (8). Doi: 10.3390/ijms18081671

Vachani, J. (2018). Failure to thrive: early intervention mitigates long term deficits. Contemporary Pediatrics. Retrieved from Walden Library Database.

SAMPLE COMPLETE SOAP NOTE: 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.

        Father – DM type 2 and MI.

        Sister – Breast Cancer.

SH: Patient smokes 2 ppd.  She does not drink alcohol.  She is retired, currently living alone.  As per patient, the only family she has is a daughter that comes and visits her 1-2 times a week.  The patient does not have a regular exercise routine.

ROS                                                                                                                                                         

Constitutionals: Denies fevers, chills, fatigue, malaise, and headache.
Head/Eyes: Denies ear pain, fullness, popping, loss of hearing, or drainage.  Denies blurry vision, eye pain, itching, or drainage.
ENMT: Denies nose drainage, loss of smell, allergies, or sinus pressure. Denies sore throat, loss of taste, difficulty swallowing, and bleeding gums.  Denies tooth pain, gum pain, and difficulty chewing.
Cardiovascular: Denies chest pain, palpitations and syncope.  Denies palpitations, orthopnea, and syncope.
Respiratory: Denies cough, shortness of breath, and sputum production.

Gastrointestinal: Denies nausea, vomiting, constipation, melena, indigestion, reflux, dysphagia, diarrhea. (+) Anorexia. Last bowel movement last night, somewhat softer than usual. No change in bowel habits. No rectal bleeding noted. (+) belching.

Genitourinary:  Denies abdominal pain/pressure, dysuria, polyuria, burning, frequency, and incomplete bladder emptying, hematuria, an offensive odor of urine, or back/flank pain.
Musculoskeletal: Denies stiffness of muscle/joints in the morning. Denies muscle cramps, articular pain, deformities, weakness, limitations to ROM
Integumentary: Denies rashes, new moles, itching, acne, or other skin changes.
Neurological:  Denies memory loss, imbalance, weakness, paralysis, numbness, tingling, tremors, disorientation, speech disorders, and involuntary movements.
Psychiatric: Denies mood changes, nervousness, depression, therapy/counseling, psychiatry disorders, and hallucinations
Endocrine: Denies Thyroid disorders, heat/cold intolerance, excessive sweating. Reports a history of DM type 2.

Objective Data:

VS: BP:135/86, HR: 95, RR: 19, Temp: 98.3, Weight: 149, height: 5’3, BMI: 26.39

       SO2: 99%.
Physical Exam:  
General: Mr. T.P is alert and awake and responding appropriately. Afebrile. Skin warm and dry.                                    
Head/Eyes: Head is normocephalic, atraumatic, and symmetrical.  Sclera and conjunctiva clear, no discharge, PERRLA.
ENMT: Neck midline, trachea midline, no lymphadenopathy were found. Bilateral external ear size, shape, and skin tone normal.  Both ears had three piercings each, no masses, or tragal tenderness.  External canal inspection reveals patent canals, without odor, discharge, or foreign bodies bilaterally.  Bilateral internal ear inspection reveals a pink canal with a tympanic membrane that is pearly gray, concave, with light reflex and visible bony landmarks, without ear cerumen.  Nares patent bilaterally, nasal septum midline, turbinates pink and moist, without nasal discharge.  Mucous membranes pink, moist without lesions, hard and soft palate intact.  Some teeth present, no teeth missing, no evidence of active decay or gum redness, no puss or bleeding visualized.  Pharynx pink, tonsils 1+ without exudates or pitting, uvula midline, tongue midline, sensitive gag response.  Maxillary and frontal sinuses non-tender tender to palpation.
Cardiovascular: Examined seated and supine. No abnormal pulsations, lifts, or heaves notes. No thrills; PMI in 5^th ICS-ML. S1 is louder at the apex, S2 louder at the base. RRR with no murmurs, clicks or gallops heard.
Respiratory: Lungs clear to auscultation, without crackles, wheezes, or rhonchi.  Normal S1 & S2 without any splits, skips, rubs, gallops, or murmurs.  No costovertebral angle or back tenderness to palpation.
Gastrointestinal Abdomen is flat and symmetrical.  No scars dilated veins, rashes, lesions, peristalsis, or pulsations visible.  Umbilicus midline, without bulges.  Bilateral abdominal stretch marks from childbirth.   Active bowel sounds in all four quadrants, no aortic, renal, iliac, or femoral bruits auscultated, no friction rubs heard over the liver or spleen.  Abdomen non-distended. BS normoactive. Pain localized to the epigastric area rated 5/10, and it does not radiate. Tympanic to percussion. No tenderness to palpation or percussion. No referred pain. No masses are palpable. Liver border 1 cm below the costal margin.                                            

Genitourinary: Abdomen soft, non-tender to light and deep palpation of upper quadrants and lower quadrants.
Musculoskeletal: Gait WNL, Muscle strength 5/5 to all groups. Joints with full ROM to all planes and w/o deformities noted. Spine with full ROM and curvature WNL; no paravertebral tenderness.
Integumentary: Overall fair without significant lesions noted; turgor good, warm ad moist. Hair distribution, texture, and quantity overall unremarkable. Nail bed pink with a good capillary refill.
Neurological: Alert, oriented in space, time, and person. No mental status noticed, Cranial Nerves 2-12 intact, DTR 2+ to upper and lower extremities; Babinski negative; Sensory intact to proprioception, sharp-dull discrimination, vibration, and stereognosis. No motor deficit noticed. The cerebellar function was intact to nose pointing and rapid alternating movements. Romberg negative                                  

Psychiatric: No suicidal ideation at this moment.

                                                         Assessment/Analysis:

Problem #1– Abdominal pain

Problem #2– Heartburn

Most likely diagnosis #1 – Gastroesophageal reflux disease – Chosen because the patient presented with burning type pain noted after eating, epigastric pain on palpation and no nausea, vomits, diarrhea, and constipation. At physical exam, we found pain localized to the epigastric area (Gyawali & Fass, 2017).

Differential diagnosis:

– Peptic Ulcer Disease: this disease could be considered because the pain presentation is consistent with PUD, but the abrupt onset of pain x 1 day is more consistent with gastroesophageal reflux disease (Ness-Jensen & Hveem, 2016).

 -Biliary disease: This disease is ruled out because the patient has a history of a Cholecystectomy (Gyawali & Fass, 2017).

– Dyspepsia: this diagnosis could be considered because the upper abdominal pain and anorexia are consistent with dyspepsia, but there is no hx of postprandial pain or early satiety (Gyawali & Fass, 2017).

Plan:

Testing:

• Consider GI referral for endoscopy. Consider testing stool for antigen H. pylori if symptoms persist.

Therapy/Treatment:

Gastroesophageal reflux disease

1. Acute treatment:
2. Omeprazole 20 mg PO q day x 2 weeks
3. After two weeks if symptoms do not subside or appear again consider testing for H. pylori or EGD

Diabetes Mellitus: Same treatment

• Metformin 500 mg BID

Education:

1. Lifestyle modifications:
2. Elevate the head of bed
3. Avoid laying down for 2 hours after meal
4. Avoid chocolate, fatty foods, peppermint, carbonated drinks, juices, especially at evening meal.
5. Chewing gum after a meal may help symptoms
6. Keep a diary of pain symptoms, relation to meals and activity, and associated symptoms.

Follow-up:

1. Return to the clinic in 3 weeks.
2. Call for worsening symptoms.

References

Gyawali, P., & Fass, R. (2017, August 05). Management of Gastroesophageal Reflux Disease. Retrieved from 

Ness-Jensen, E., & Hveem, K. (2016). Exam 1: Lifestyle Intervention in Gastroesophageal Reflux Disease. Clinical Gastroenterology and Hepatology,14(2). doi:10.1016/j.cgh.2015.12.003