Topic: Soap Note

Identification\ Problem Recognition

Patient initial

C.K

Nationality

Saudi

Age

28 years

Sex

Male

Source of information

Patient

Problem Statement

I have been experiencing burning chest pains, regurgitation, and acid tastes in the mouth. This happens mostly after taking a meal or snack and it makes me uncomfortable.

HPI

When examined, the patient said that he had been experiencing severe heartburns for the last three weeks. He also suffered from hernia where stomach contents would reflux and move upwards to the oesophagus. Two weeks ago, he could not control the situation and he started experiencing coughs and vomiting. The patient also said that he was experiencing acid irritations along the windpipe. Other symptoms shown by the patient include hoarseness, sore throat, throat lumps, and chronic sinusitis.

PMH

The patient had been experiencing heartburns for the last one year. He had relied on anti-acids all along and the situation was controlled for some time but it has reappeared once again.

Surgical History/Hospitalization

The patient has never been to surgery and has never been hospitalized. He usually buys over the counter drugs.

Family History

Only his sister experienced GERD when she was pregnant but she was okay after conceiving. There is no concrete evidence of other family members suffering from GERD.

Social History

The patient is a Muslim. He is a mechanical and production engineer by profession. He is a smoker but does not sniff tobacco.

Allergies

The patient has no allergy to food or any drugs. He sometimes experiences nasal blockage when exposed to dust or cold. He takes asthma spray to take care of the situation.

MEDS.

The patient is on omeprazole 40 mg and Antacid 5mg daily. The meds are taken orally. The patient has also changed feeding lifestyle by avoiding acidic foods.

Immunization

The patient has received the mandatory childhood and adulthood immunizations since he was a child. He has received Whooping cough and tetanus immunization.

ROS

HEENT

Head: the patient has been experiencing severe headaches after hernia.

Eyes: The patient experiences dizziness and eye pain when exposed to direct sunlight. He started wearing glasses after he started having blurred vision.

Ears: The patient has no ear problems.

Nose: no nosebleeds but there are nasal itching and blockage when exposed to dust.

Throat: the patient has difficulty in swallowing. He also has nausea and vomits severally especially after eating or drinking. The patient cannot swallow heavy meals.

RESP.

The patient has dry cough The patient has a normal breath.

CV

The patient has severe chest pains.

GI\GU

The patient has nausea and vomiting. He has a normal bowel movement and there is no pain reported after long and short calls.

MSK

The paint has no joint pains.

SKIN

The patient has dry skin with rashes

Mental

He has never had psychiatric conditions. He is not confused and he speaks fluently. Can interpret idea and communicate effectively.

OBJECTIVE DATA

&

PHYSICAL ASSESSMENT

V\S

Respiration rate: 21 breaths per minute.

Blood Pressure: 120/80mmHg

Temp. 37.0 C .

Ht: 176 cm.

Heart rate: 100 b/m.

Wt: 82kg.

BMI = 26.5.

General Appearance

The patient seems to be moody and exhausted.

HEENT

H: The head is okay, no hair loss.

Eyes: The eyelids are normal, no scars or discharge.

Ears. The patient does not have vertigo or any hearing impairment. Also, no discharge.

Nose: he has a running nose. Claims that he was exposed to dusty conditions while at work.

Throat: the patient has larynx inflammation and swollen lymph nodes.

Neuro.

The nerve system is okay, no nerve damage.

CV

The pulse rate of the patient is 100 b/m and the blood pressure is 120/80 mmHg.

RESP.

The patient has a dry cough and wheezes a lot at night or after jogging or performing a small task.

GI \ GU

Although there are chest pains, X-ray shows that chest muscles are okay, do damaged ligaments. The pharynx is reddish and swollen. There are no abdominals scars and the bowel movement is normal.

Skin

The skin is dry and pale with rashes.

Musculoskeletal

There are no fractures.

Mental

The patient is moody and worried.

DIAGNOSTIC TESTS

· Oesophageal pH Test.

· Acid reflux test.

· upper endoscopy test.

· Esophageal manometry test.

· PPI therapy.

· Ambulatory acid probe test.

Diagnostic test results:

· Oesophageal pH Test- (2.0)-highly acidic

· Acid reflux test-pictures of the oesophagus show that the oesophagus and stomach walls have ulcers.

· Upper endoscopy test is carried out to evaluate the effectiveness of the ambulatory acid probe test.

· Esophageal manometry test- particles of food were found on the sphincter.

· PPI therapy- the oesophagus was found to be highly acidic.

· Ambulatory acid probe test- it was noted that the patient alternating levels of acid reflux ranging 2.0-4.0.

Final Diagnosis

Gastroesophageal Reflux Disease (GERD).

DIFFRENTIAL DIAGNOSIS

Diagnosis

Positive findings

Negative findings

Coronary

Artery Disease (CAD).

Cardiac etiology must be done before doing a diagnosis for GERD patients with severe chest pains.

The test may differ; ECG can show Q or ST changes.

Oesophageal disorder.

Severe chest pains are always substernal due to exertion and can be relieved by having some rest.

Stress testing may subject the patient to abnormal/irrelevant tests.

Peptic ulcer disease.

Burning pain/sensation in the epigastrium, may occur after meals. The patient is uncomfortable at night and it can be controlled by taking some food or antacids.

Endoscopy shows the presence of ulcers. The test for Helicobacter pylori is positive but not diagnostic.

Eosinophilic esophagitis

Esophagitis,eosinophilic, and features of GERD overlap. Symptoms are not detected at older ages.

Endoscopy shows linear furrows, exudates, white plaques, and oesophageal rings at the base of the oesophagus. The number of eosinophil is higher than that of typical GERD. It can be more than 15 in every sampled oesophageal tissue.

Proton pump inhibitor.

This is done when the patient has oesophageal problems but he demonstrates proton-pump inhibition symptoms.

Therapeutic response is done to PPI. PPI dose should be similar to those of erosive esophagitis with duration of more than 8 weeks. There must be a follow-up after biopsy and endoscopy.

Plan

Nonpharmacological treatment

One of the causes of GERD is excessive eating and smoking. The patient should take action and revise his diet by taking light meals for easy digestion and also taking a lot of water (Pallati et al, 2014 p. 505).

Pharmacological Treatment

DRUG

General Considerations

GERD medications:

Omeprazole 500mg daily.

Antacid 5mg daily.

receptor antagonists 5mg twice a day .

Histamine-2 (H2) 500mg daily.

The total medication time is about 14 days in total.

It cannot exceed or go below that.

Adrenergic agonists may lead to nausea and oversleeping and therefore the patient should take caution.

Surgery/Other Procedures

When medications do not comply, surgery can be done to reduce size of hernia. Surgery is not an option for this patient because it requires a stronger evidence and recommendation.

Follow Up

The patient is advised to take full medication for 3 months. He should also book an appointment with a doctor after every one week to go for check-up.

Education

-The patient should first quit smoking. The oesophageal sensations and irritations may be due to cigarette smoke. Also, the patient has dust allergy and should avoid smoky areas by all means (Tan et al, 2016 p. 5).

-The patient should be advised on the best diet to reduce the level of acidity along the oesophagus. He should avoid acidic foods like peppermint, chocolate, tomatoes, spicy foods, caffeine, citrus fruits, and onions.

-The patient should drink a lot of water to avoid dehydration due to vomiting.

-Stomach PH should be monitored, also check presence of ulcers.

-Lifestyle modifications are very important while trying to eliminate GERD symptoms. Patients are advised to undergo pharmacologic therapy.

- Depending on the symptoms and level of acidity. Severe GERD is handled by PPI therapy to ensure a faster recovery (Pallati et al, 2014 p. 505).

-Also, another measure is to maintain a healthy weight.

GERD is caused by overweight and GERD patients should control their weights.

-Also, one should avoid lying down after meals and avoid eating late at night (Ganz et al, 2013 p. 722).

-It is also advisable to raise the bed on the head side and avoid wearing tight fitting clothes.

-Not all GERD medicines are good since some may worsen the situation. Such drugs include theophylline, calcium blockers, and anticholinergic drugs. Also, patients should avoid anti-inflammatory drugs like ibuprofen and asprin unless recommended by a health provider.

Referral

Refer to dietician.

Learning Resources

Ganz, R.A., Peters, J.H., Horgan, S., Bemelman, W.A., Dunst, C.M., Edmundowicz, S.A., Lipham, J.C., Luketich, J.D., Melvin, W.S., Oelschlager, B.K. and Schlack-Haerer, S.C., 2013. Esophageal sphincter device for gastroesophageal reflux disease. New England Journal of Medicine, 368(8), pp.719-727.

Kavitt, R.T. and Vaezi, M.F., 2016. Gastroesophageal Reflux Disease. Practical Gastroenterology and Hepatology Board Review Toolkit, pp.85-90.

Khan, S. and Orenstein, S.R., 2018. Gastroesophageal reflux disease. Current and Future Developments in Surgery Volume 1: Oesophago-gastric Surgery, 1, p.189. retrieved from: https://medbroadcast.com/channel/digestive-health/related-conditions/gerd- gastroesophageal-reflux-disease

Tan, V.P.Y., Wong, B.C., Wong, W.M., Leung, W.K., Tong, D., Yuen, M.F. and Fass, R., 2016. Gastroesophageal Reflux Disease. Journal of clinical gastroenterology, 50(1), pp.1-7. Retrieved from: https://www.webmd.com/heartburngerd/guide/heartburn_gerd_diagnosis_tests