LAU SOAP 1

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Demographics

Patient Initials: R.K

Age: 45-year-old

Race: White

Ethnicity: Caucasian

Gender: Male.

Chief Complaint (Reason for seeking health care)

“I keep having a burning feeling in my chest after eating.”

History of Present Illness (HPI)

The patient, R.K., is a 45-year-old man, complaining of heartburn. The symptoms began 4 weeks ago (onset) and is localized to the epigastric and retrosternal (location). The symptoms are periodic (frequency) and chronic (duration) and prone to burning sensation (character). Sometimes, lying down, consuming spicy or fatty foods (aggravating factors) and antacids (relieving factors) aggravate and alleviate the discomfort, respectively. The symptoms are mainly post-meal and night (timing) and 6/10 on the severity scale (severity). The patient also reports about the regurgitation and sour mouth.

Allergies

The patient denies allergies to medications, food, environmental, herbs, and latex (NKDA).

Review of Systems (ROS)

General: The patient denies fever and chills and weight loss, complains of mild discomfort.

HEENT: The patient denies any headaches, blurred vision, ear pain, and nasal congestion, she claims that her throat is sore.

Neck: Denies any neck stiffness, pain, lymphadenopathy.

Lungs: The patient denies any shortness of breath, cough, and wheezing.

Cardio: The patient denies palpitations and edema, complains of burning pain in the chest.

Breast: The patient denies the presence of tenderness, lumps, discharge.

GI: Patient denies nausea, vomiting, diarrhea, abdominal pain, heartburn and regurgitation, and has a sour taste.

M/F genital: The patient denies lesions, discharge or pain.

GU: The patient denies dysuria, urgency, frequency, and hematuria.

Neuro: The patient denies a feeling of dizziness, weakness, numbness, or tingling.

Musculo: The patient denies any joint pain or swelling.

Activity: The patient denies experiencing intolerance to exercise, discomfort after eating and affecting activity.

Psychosocial: The patient denies depressions or anxiety, states some slight stress.

Derm: The patient denies having any rashes or skin changes.

Nutrition: The patient claims to often consume fatty and hot food and denies having food restrictions.

Sleep/Rest: The patient admits that she has disrupted sleep, which is due to nighttime symptoms, and does not take any sleep aids.

LMP: Does not apply due to patient being a male.

STI Hx: The patient denies sexually transmitted diseases.

Vital Signs

BP:130/84mmHg (sitting position)

HR- 82bpm.

RR 16 breaths/minute.

Temp- 36.7 C.

Wt: 88 kg.

Ht:175 cm.

BMI:28.7 kg/m².

Pain: 6/10.

Labs

No lab tests that were ordered at this visit

Medications

The patient does not take any over-the-counter antacids. There are no other drugs reported.

Past Medical History

Diagnosis of obesity in 2020 (active).

Denies gastrointestinal disease

Past Surgical History

The patient denies any prior surgeries.

Family History

Father-high blood pressure.

Mother-type 2 diabetes mellitus.

Brother- is in good health.

Grandfather -was a paternal stomach cancer patient.

Social History

The patient does not use tobacco or illicit drugs, but at some instances, she takes alcohol. He is a married and office worker. He is a straight man, sexually active and has a single partner. He has no birth control. He lives with his family.

Health Maintenance/ Screenings

The patient was immunized (COVID-19 and influenza vaccines). Blood pressure and BMI are periodically monitored. No history of endoscopy. Otherwise, regular screening is up-to-date.

Physical Examination

General: The patient is awake and oriented to person, place, time, and situation and does not seem to be in acute distress. The patient is well nourished and well groomed.

HEENT: Head is normal and untraumatized. The mucosa of the mouth is wet and intact. There is mild pharyngeal irritation without erythema or exudate. Pupils are round, equal and responsive to light. Ears are symmetric with pearly gray tympanic membranes.

Neck: Neck is supple and with full range of motion. No mass, tenderness or lymphadenopathy. There is no jugular venous distention.

Lungs: Both lungs have clear sounds to auscultation. No wheezes, rales, or crackles.

Cardio: The rate and rhythm of the heart are regular. No murmurs, rubs, and gallops are observed. Bilateral equality of peripheral pulse. S1 and S2 present.

GI: The abdomen is round and not distended. Mild palpable epigastric tenderness. No guarding, rebound tenderness or masses. All quadrants have bowel sounds.

Musculoskeletal: No deformities, swelling, or tenderness of joints. Full and intact range of motion of all extremities.

Neurological: Patient is alert and oriented ×4. The cranial nerves II-XII are intact. Bilateral motor strength and sensation are normal. Reflexes normal.

Derm: Warm, dry, intact skin. There are no lesions, rashes or discoloration

Diagnosis

Primary Diagnosis: GERD- K21.9

Gastroesophageal reflux disease is a lasting disorder that is brought about by the retrograde movement of gastric contents into the esophagus resulting in symptoms that comprise of heartburn, regurgitation, and chest pains (Roman et al., 2022). This diagnosis is supported by the fact that the patient has the symptoms of burning after meals, which are enhanced by lying down and alleviated by antacids.

Differential Diagnosis

Peptic Ulcer Disease - K27.9

Peptic ulcer disease is characterized by the gastric mucosal or duodenal mucosal erosion, which is commonly due to infection by Helicobacter pylori or use of NSAIDs. It is characterized by epigastric pain, nausea and potential bleeding. Though this patient experiences epigastric pain, the lack of intense pain and bleeding rules out such a diagnosis.

Gastritis- K29.70

Gastritis is inflammation of the stomach lining, which is usually due to alcohol consumption, drugs, or infection. It is characterized by epigastric pain, nausea and indigestion (Choi et al., 2024). Although this patient complains of mild tenderness in the epigastric region, the main symptom of reflux and regurgitation is the leading cause of gastritis is not the first-line diagnosis.

Esophagitis- K20.9

Esophagitis inflammation is inflammation of the esophagus lining, which is frequently caused by acid reflux, infection, or by the irritation of the mucous membrane by medications (Maskey et al., 2022). It can exhibit itself in the form of heartburn, chest pains, and difficulty in swallowing. The patient has reflux symptoms, but lacks dysphagia or odynophagia, so esophagitis is less likely to be the diagnosis.

ICD 10 Coding

ICD10-K21.9

ICD10-K27.9

ICD10-K29.70

ICD10-K20.9

Pharmacologic treatment plan

Omeprazole 20 mg PO once daily 8 weeks (cost 10-20); take in the morning before meals, observe headache or diarrhea. PRN to treat the symptoms (price $5-10). Educate patient on how to take medication, avoiding triggers, and not lying down after eating to control the symptoms

Diagnostic/Lab Testing

No diagnostic tests are required currently. Endoscopy may be prescribed in case the symptoms do not fade or when they become more severe

Education

· The patient was educated on avoiding spicy, fatty and acidic food.

· The patient was advised to eat less and avoid lying down after eating.

· The focus on weight management and alcohol limitation was underlined.

· The patient was educated on be proper hydrated to prevent the increased of acid formation.

Anticipatory Guidance

· Good food and weight control is primary prevention.

· Secondary prevention entails symptoms monitoring and pursuing treatment when there is escalation of symptoms or complication.

Follow up plan

The patient will report in 4 weeks so that the progress of the symptoms can be evaluated.

References

Choi, W., Lauwers, G. Y., & Slavik, T. (2024). Inflammatory disorders of the stomach. 135–194. https://doi.org/10.1002/9781119423195.ch11

Maskey, A., Srivastava, K., Soffer, G., Dunkin, D., Yuan, Q., & Li, X.-M. (2022). Induction of Severe Eosinophilic Esophagitis and Multi-Organ Inflammation by Airborne Allergens is Associated with IL-4/IL-13 and CCL11 but Not IgE in Genetic Susceptible Mice. Journal of Inflammation Research, Volume 15, 5527–5540. https://doi.org/10.2147/jir.s372449

Roman, S., Pandolfino, J. E., & Kahrilas, P. J. (2022). Gastroesophageal reflux disease. Yamada’s Textbook of Gastroenterology, 815–838. https://doi.org/10.1002/9781119600206.ch43

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)__RK___________________ Age _45__________

Date: __04/23/2026__________

RX __ Omeprazole 20 mg

SIG: 1 tablet by mouth/day in the morning, before meals

Dispense: Refill: 30 tablets

No Substitution

Signature:____________________________________________________________