GERD SOAP NOTE

Name

Course Title

Instructor

Due Date

Choice of Patient

Mr.D, 50, complains of a "burning sensation at chest, especially after eating, since two months, became severe last few days," regurgitation of sour liquid or food, sleeplessness, nighttime cough, upper stomach ache, nausea, and weakness. He stated that he used to consume more coffee than any other beverage, as well as a drink every evening, but he did not smoke. He claims to be a non-vegetarian who prefers meat and animal products over vegetables, and he used to eat meals late at night. He also confessed that "'OTC drugs that were previously effective for heartburn are no longer effective."

Subjective

Chief Complaint 

Male patient Mr. D, 50, comes in complaining of a "burning sensation at the chest, especially after eating, in the last two months, which has become severe in the last few days." In addition, he describes feeling weak, coughing up sour fluids or food at night, feeling sleep-deprived, and having upper stomach pain and nausea. Mr. D reveals that he used to have a drink every evening and more coffee than anything else, but he does not smoke. He used to consume meals late at night and claims to be a non-vegetarian who favors meat and animal items over veggies. Additionally, according to Mr. D, over-the-counter (OTC) medications that used to be beneficial for treating heartburn are no longer effective.

History of Present Illness

Mr. D, a fifty-year-old man, has been experiencing a burning feeling in his chest, particularly after eating, for two months. He says that throughout the previous three days, the symptoms have been worse. He has been feeling nausea, weakness, an upper stomach ache, a nightly cough, regurgitation of sour drinks or food, and insomnia, in addition to chest discomfort. Mr. D claims that he used to drink coffee every evening and drink more coffee than any other beverage. But he says he doesn't smoke. He used to eat dinner late at night and considers himself as a non-vegetarian who favors meat and animal items over veggies. The patient also reports that the over-the-counter (OTC) drugs that were used to help him with his heartburn are no longer working. He is upset about how his symptoms are getting worse and how this is affecting his quality of life. 

Past Medical History 

1. Chronic Hypertension 
2. Type 2 diabetes

Family History/Genetic Risk Factors:

Mother: Coronary artery disease, cervical cancer, heart failure

Father: Coronary artery disease, myocardial infarction

Son: Hypertension, COPD (deceased)

Brother: Brain cancer, lung cancer, melanoma, coronary artery disease, diabetes mellitus

Sister: Atrial fibrillation, brain cancer, coronary artery disease, myocardial infarction (deceased)

Allergies:

1. Codeine - causes hyperactivity
2. Prednisone - causes swelling

Medication Information: 

Medication Class	Medication	Dosage (Inpatient)	Dosage (Outpatient)
Proton Pump Inhibitors (PPIs)	Omeprazole	Oral: 20-40 mg once daily	Oral: 20-40 mg once daily before breakfast
	Esomeprazole	Oral: 20-40 mg once daily	Oral: 20-40 mg once daily before breakfast
	Pantoprazole	Oral: 40 mg once daily	Oral: 40 mg once daily before breakfast
Histamine-2 Receptor Antagonists (H2RAs)	Ranitidine	Oral: 150 mg every 12 hours	Oral: 150 mg every 12 hours
	Famotidine	Oral: 20-40 mg every 12 hours	Oral: 20-40 mg every 12 hours
Antacids	Calcium Carbonate	As directed by a healthcare provider	As directed by a healthcare provider
	Magnesium Hydroxide	As directed by a healthcare provider	As directed by a healthcare provider
Alginate-based Formulations	Gaviscon	As directed by a healthcare provider	As directed by a healthcare provider

Health Maintenance/ Promotion

Immunizations: Current on tetanus, MMR, influenza, and COVID-19 boosters. Pneumococcal vaccination status is unknown.

Ongoing Medical Care: Established with a primary care provider. Has never seen his cardiologist in a few years.

Social History/ Lifestyle Choices

Mr. D is a 65-year-old retired teacher who lives alone after being divorced. He used to smoke heavily; for thirty years, he smoked one pack of cigarettes a day; however, he gave up the habit ten years ago. He acknowledges that he occasionally relapses, particularly in times of stress. Mr. D's diet is comprised mostly of takeout and convenience foods at the moment because he finds it difficult to cook because of his limited mobility. He admits to occasionally drinking alcohol as well; usually, he drinks a glass of wine with supper. Despite his health issues, Mr. D remains involved in his community. He serves as a volunteer at the local senior center and attends church every week. This engagement points to a robust social support system, which may help him manage the psychological and emotional effects of his long-term illness. However, Mr. D is upset and concerned about his health failing, especially as it affects his day-to-day activities. He doesn't undertake any aerobic exercise or indulge in sexual activity at the moment. This extensive social history and lifestyle information gives valuable context for understanding the likely causes of Mr. D's gastroesophageal reflux disease. His food choices, dietary history, and sporadic alcohol use are all recognized risk factors for the onset and exacerbation of GERD symptoms. His restricted movement and difficulties preparing meals could also make him more dependent on unhealthy food options. Effectively managing Mr. D's GERD will require addressing these lifestyle issues.

Assessment in Soap Note

Cultural/ Spiritual Considerations 

Mr. D still firmly believes in God, having grown up as a Baptist. As part of his spiritual and social engagement, he actively participates in weekly church services and volunteers at the local senior center. He claims he hasn't felt nervous or depressed in the last two weeks, but he does admit to feeling alone and lonely most of the time. His comprehensive care plan will take into account his social needs and cultural and spiritual background in order to address his physical, emotional, and psychological well-being comprehensively.

Quality of Life Considerations

The multiple chronic conditions that Mr. D suffers from significantly affect his quality of life. These conditions include hypertension, type 2 diabetes, COPD, and gastroesophageal reflux disease (GERD). He experiences difficulties with daily duties, exacerbations of his conditions, and persistent respiratory and gastrointestinal issues as a result of his decreased mobility and functional capacity. It serves as a reminder of how important it is to tend to not just his physical requirements but also his mental health and social support system because of his fury and grief over his failing health and how it is affecting his freedom. It is essential to collaborate with a multidisciplinary team that includes a Clinical Nurse Specialist (CNS) to develop an extensive treatment plan that is tailored to his particular needs and circumstances, with an emphasis on improving his quality of life as a whole. 

Review of Systems:

Constitutional: Reports baseline fatigue.

Head/Face: The initial post-fall headache was resolved.

Eyes: Wears reading glasses. Denies acute visual changes or dry eyes.

Ears: No hearing impairment.

Nose: Pre-admission sinus symptoms resolved. Denies epistaxis.

Mouth: Denies bleeding gums or issues with intake.

Neck/Lymph/Thyroid: Denies tenderness or swelling.

Cardiovascular: Denies chest pain or palpitations. CHA2DS2-VASc score 7.

Respiratory: Presents a chronic cough (productive - coughing up phlegm), shortness of breath (ongoing and worsening), and exacerbation of respiratory symptoms during winter months.

Abdomen/GI: Reports heartburn, regurgitation, and dysphagia.

GU: Denies urinary symptoms and occasional stress incontinence.

Integumentary: Denies wounds or rashes. Bruises easily.

Musculoskeletal: Denies chronic/acute pain. High fall risk, afraid of falling again. FRAX score: Major fracture 19%, hip fracture 7.5%.

Neurological: Denies dizziness or seizure symptoms; bilateral foot neuropathy with paresthesia and pain.

Psychiatric: The patient reports frustration and emotional distress due to his condition.

Objective

Vital Sign	Measurement	Normal Range
Blood Pressure (BP)	140/90 mmHg	<120/80 mmHg
Heart Rate (HR)	80 bpm	60-100 bpm
Respiratory Rate (RR)	16 breaths/min	12-20 breaths/min
Temperature (T)	98.6°F (37°C)	97-99°F (36.1-37.2°C)
Oxygen Saturation (SpO2)	98%	>95%

Test	Result	Normal Range
Complete Blood Count (CBC)	Within normal limits
Basic Metabolic Panel (BMP)	Glucose: 120 mg/dL Sodium: 138 mEq/L  Potassium: 4.0 mEq/L  BUN: 20 mg/dL Creatinine: 0.9 mg/dL Calcium: 9.0 mg/dL	Glucose: 70-100 mg/dL Sodium: 135-145 mEq/L Potassium: 3.5-5.0 mEq/L BUN: 7-20 mg/dL Creatinine: 0.6-1.2 mg/dL Calcium: 8.5-10.5 mg/dL
Liver Function Tests (LFTs)	Within normal limits	-
HbA1c	7.2%	<5.7% (non-diabetic)
Lipid Profile	Total Cholesterol: 220 mg/dL LDL Cholesterol: 150 mg/dL HDL Cholesterol: 40 mg/dL Triglycerides: 180 mg/dL	Total Cholesterol: <200 mg/dL LDL Cholesterol: <100 mg/dL HDL Cholesterol: >40 mg/dL (men), >50 mg/dL (women) Triglycerides: <150 mg/dL

Radiology Report:

Upper GI Endoscopy:

Findings: Evidence of erosive esophagitis with multiple ulcerations in the distal esophagus. Hiatal hernia measuring approximately 2 cm. Impression: Grade C erosive esophagitis according to the Los Angeles classification. Hiatal hernia present.

Chest X-ray:

Findings: No acute abnormalities. Impression: Within normal limits.

Abdominal Ultrasound:

Findings: Mild hepatomegaly noted. There is no evidence of gallstones or biliary obstruction. Impression: Mild hepatomegaly, otherwise unremarkable.

Physical Exam.

General Survey: 

System	Findings
General Appearance	Mr. D appears to be his stated age of 50. He is alert and oriented, sitting comfortably in the examination room. He seems tired but not in acute distress.
Vital Signs	Blood Pressure: 140/90 mmHg, Heart Rate: 80 bpm, Respiratory Rate: 16 breaths/min, Temperature: 98.6°F (37°C) and Oxygen Saturation: 98%
HEAT	Head: Normocephalic, atraumatic. Eyes: Pupils equal, round, reactive to light. No conjunctival pallor or icterus. Ears: Tympanic membranes intact bilaterally, no discharge or erythema. Nose: Nasal mucosa is moist, and there is no evidence of septal deviation or polyps. Throat: Oropharynx clear, moist mucous membranes, no lesions or exudates.
Neck	Supple, no jugular venous distension. No palpable lymphadenopathy or thyroid enlargement. Negative for bruits.
Cardiovascular	Regular rate and rhythm, no murmurs, rubs, or gallops. Peripheral pulses intact bilaterally. No lower extremity edema.
Respiratory	Clear to auscultation bilaterally, no wheezing, rales, or rhonchi. Respiratory effort within normal limits.
Abdomen	Soft, non-tender, non-distended. No hepatosplenomegaly is appreciated. Positive epigastric tenderness upon palpation. No rebound or guarding.
Musculoskeletal	Full range of motion in all extremities. No joint deformities or swelling were noted. Negative for costovertebral angle tenderness.
Neurological	Alert and oriented to person, place, and time. Cranial nerves II-XII intact. No focal deficits are appreciated. Sensation intact bilaterally.
Skin	Warm and dry, no rashes, lesions, or signs of trauma. Bruises were noted on bilateral lower extremities.
Psychiatric	Cooperative and engaged in conversation. Affect appropriate to conversation content. Denies suicidal ideation or hallucinations.

Assessment and Plan

Gastroesophageal Reflux Disease (GERD):

Mr. D exhibits typical GERD symptoms, such as an upper stomach ache, a burning sensation in the chest, and the regurgitation of sour food or liquids at night. A hiatal hernia and grade C erosive esophagitis are confirmed by endoscopic findings. Mr. D's past smoking, eating choices, and sporadic alcohol usage probably make these symptoms worse.

Chronic Conditions:

Hypertension and type 2 diabetes are well-controlled but require ongoing management. His HbA1c of 7.2% suggests suboptimal glycemic control, necessitating possible adjustments to his diabetic regimen.

Musculoskeletal Issues:

Mr. D reports bilateral foot neuropathy with paresthesia and pain, increasing his fall risk. Additionally, he has concerns about decreased mobility and fear of falling.

Psychological Distress:

Mr. D expresses frustration and emotional distress regarding his worsening health and its impact on his daily life. He also reports feelings of loneliness and isolation.

Plan:

GERD Management:

1. Initiate treatment with a proton pump inhibitor (PPI) at maximum dosage for symptomatic relief of GERD.
2. Recommend lifestyle modifications, including avoiding late-night meals, alcohol, caffeine, and acidic/spicy foods.
3. Follow up with a gastroenterologist for further evaluation and consideration of surgical intervention for hiatal hernia if symptoms persist despite medical therapy.

Diabetes Management:

1. Adjust diabetic regimen to improve glycemic control, potentially adding or adjusting medications as indicated.
2. Provide dietary counseling and encourage regular physical activity to optimize diabetes management.

Hypertension Management:

1. Continue current antihypertensive regimen, with periodic monitoring of blood pressure and adjustment of medications as needed.

Fall Risk Reduction:

1. Refer Mr. D to physical therapy for gait and balance training to reduce fall risk.
2. Recommend environmental modifications at home to enhance safety.

Psychological Support:

1. Offer counseling services or referral to a mental health professional to address Mr. D's emotional distress and feelings of loneliness.
2. Encourage participation in support groups or social activities to promote social engagement and emotional well-being.

Follow-up:

1. Schedule follow-up appointments with a gastroenterologist, primary care provider, and diabetic educator as appropriate to monitor response to treatment and address any concerns.
2. Arrange for home health services if needed to assist with activities of daily living.