Tina Jones Gastrointestinal Assessment Soap Note

Tina Jones SOAP Note

Date & Time

  1. Problem List
  2. Active problems: postprandial epigastric pain lasting a few hours; loss of appetite, increased frequency of urination, and nocturia.
  3. Inactive problems: Bronchial Asthma, Diabetes Mellitus Type II,
  4. Risk factors: alcohol intake, obesity, dietary intake of carbonated beverages,

Tina Jones Gastrointestinal Assessment Soap Note

Chief Identifying Data

Name: Tina Jones

Gender: Female

Informant: The Patient

Chief Complaint: “I have frequent stomach pain that comes after meals”

History of Presenting Illness: Tina Jones is a 28-year-old black female with frequent upper abdominal pain that comes after meals. she started experiencing the pain about a month ago. It was of gradual onset and has since increased gradually in severity.  It is worsened by taking larger meals, spicy foods, bending over, and lying supine. However, the pain is not worsened by fatty foods. The severity of the pain improves with upright posture, and between meals.

The pain comes daily and the episodes vary in severity: three to four episodes in a week are more severe than the other days. Currently, the pain is mild (1-2 out of 10) while more severe episodes are rated 5/10. The severity of the pain varies with posture such that when she lies supine the severity of the pain increases to 6/10. The pain starts immediately after meals and usually lasts “a few hours” before subsiding in during each episode.

The pain is similar to ‘heartburn’ in character. She denies crushing or gnawing pain and there is no subjective abdominal tenderness when she touches the abdomen. The pain is located centrally in the upper abdomen and does not radiate. Tina Jones Gastrointestinal Assessment Soap Note. She denies pain in the flanks, arms, shoulders, or back. She reports eating smaller quantities of food and a decrease in her appetite whenever she anticipates the pain.

She has since avoided spicy foods because of their association with pain aggravation. She also reports burping that occasionally occurs after eating. No weight loss has been reported since the onset of the pain. Her bowel movements are consistent and come every two days. She denies tarry, bloodstained, or mucus in stool. Her urinary frequency has increased but with no pain during urination. She reports nocturia but the urine is not pinkish or bloody. There is no urinary incontinence or change in urine color or character of urination.

Medical History:

Current Medications: she reports occasional use of Tums, an antacid. No new medications are reported. Tums partially relieves her pain after she takes between two and four tablets at a time every few days. She doesn’t use Advil for the pain.

Allergies: in the last visit the patient reported allergies to latex and penicillin. However, there are no new allergies reported.

Past Medical History: Tina Jones is a known type II diabetes patient and asthmatic since age childhood. The last hospitalization was at age 16 due to acute asthmatic exacerbation. No history of past surgeries is reported. She reports no history of gastrointestinal ulcers, gastroesophageal reflux disease (GERD), liver disease, urinary disease, or cholecystitis. She is not hypertensive but reports an incident when her physician told her blood pressure that rose.

Social History: her last meal was toast and honey and butter, and orange juice. She typically takes three meals and a snack in a day. Typically, she takes three fast foods per week. Her typical snacks are pretzels, French fries, chips, or crackers.  She took cereal for breakfast, pizza for lunch, and baked potato for dinner yesterday. She reports a positive intake of alcoholic beverages.

She takes two to three drinks in one seating about 2-3 times a week.  She reports taking 3-4 bottles of coke a day that she doesn’t associate with the postprandial upper abdominal pain. She also drinks 6-8 glasses of water a day. She neither uses illicit recreational rugs nor smokes tobacco. No history of recent travels of food poisoning is reported. She lives near a grocery with access to fresh foods.

Reproductive History: she is not sexually active and her last menstrual period was 3 weeks ago.

Family History: there is no history of GERD, liver, or urinary disease in the family. The father was diabetic hypertensive and had high cholesterol. The sister is asthmatic while the brother is obese. The mother is hypertensive and has high cholesterol.

Review of Systems:

GENERAL: no fever, fatigue, weakness, chills, or weight changes

RESPIRATORY SYSTEM:  no cough, difficulty in breathing, chest pain, or sore throat

GASTROINTESTINAL SYSTEM: no dysphagia, no loss of taste, flatus, constipation, diarrhea, nausea, or vomiting

CARDIOVASCULAR SYSTEM: no palpitations, exertional dyspnea, or chest tightness

GENITOURINARY SYSTEM: she reports the increased frequency of urination, nocturia, with the yellow color of urine, no dysuria or hematuria

MENTAL HEALTH: she reports occasional anxiety feelings and stress related to school work, no depression of mood or hallucinations

NEUROLOGICAL: no loss of bladder or bowel control

Objective

General and Mental State: Tina Jones is a 28-year-old American in good general condition. She is not in any obvious distress. She is oriented in place, time, and person. She interacts well with the examiner and maintains good eye contact throughout.

Abdominal Examination:

Inspection: The skin turgor assessment shows no tenting. The contour is protuberant without visible scars, masses, striae, rashes, or distension. The abdomen is symmetrical.

Auscultation: There are no adventitious sounds heard in anterior and posterior abdominal regions. Bowel sounds are normoactive in all four abdominal quadrants.

Percussion: percussion note for the spleen was tympanic as well as all other areas of the abdomen. There was no CVA tenderness. The liver span was between 6 and 12 centimeters

Palpation (light/superficial): no tenderness, masses, guarding, or distension in all quadrants of the abdomen.

Palpation (light/superficial): no palpable mass in all quadrants of the abdomen. The liver was palpable while the spleen was not. The left and the right kidneys were not palpable.

Cardiovascular Exam: S1 and S2 heart sounds were heard and there are no added heart sounds. The pulse had a regular rate and rhythm. No bruits were auscultated over the abdominal aorta, left & right renal, iliac, and femoral arteries.

Respiratory Exam: the chest is symmetric and moves with respiration. Normal breath sounds present in all lung fields. No wheezes or crackles were auscultated in the anterior and posterior lung fields. Tina Jones Gastrointestinal Assessment Soap Note

Assessments

  1. Gastroesophageal Reflux Disease (GERD)

GERD presents with typical and atypical symptoms. Typical symptoms include the heartburn sensation after meals, regurgitation, and dysphagia (Chuang et al., 2017). Atypical symptoms include but are not limited to coughing, wheezing, and chest pain (Patti & Anand, 2020). Depending on the severity, GERD can present with complications due to constant acid erosion that is untreated or undertreated. Tina Jones most likely had an uncomplicated GERD.

She complained of postprandial retrosternal pain lasting few hours. The usual increase in gastric acid secretion above that basal secretion occurs in response to meals. however, this may occur in other pathological conditions as well. The reflux of this acid into the esophagus, which is not histologically structured to handle acidic contents, causes erosion and pain. Tina jones denied some typical presentation of GERD. Basing diagnosis on typical symptoms may be correct in only 70% of patients with GERD (Patti & Anand, 2020 Tina Jones Gastrointestinal Assessment Soap Note).

Complicated GERD may also present with dysphagia among other sequelae such as odynophagia, unintended weight loss, hematemesis, or vomiting. These symptoms were absent in Tina Jones. Moreover, Tina’s symptoms were worsened by spicy foods, large meals, bending over, or lying supine. The reflux in GERD is usually caused by relaxation of the lower esophageal sphincter or an increased in intraabdominal pressure that was likely pathophysiology mechanisms in Tina Jone’s condition.

  1. Peptic Ulcer Disease (PUD):

Peptic Ulcer Disease presents almost similarly to GERD. The difference in presentation arises from pathophysiology. The erosion by the acidic gastric contents occurs on the gastric mucosa in PUD. The patient’s BMI, obesity, (Kim et al., 2017) places her at the risk of PUD. Other etiologies such as the use of NSAIDs were ruled out by the patient’s history. PUD usually present with postprandial nausea or vomiting (Malik et al., 2020) both of which the patient denied.

Gastric PUD usually presents with pain about ten to fifteen minutes after meals while duodenal PUD takes up to half an hour to manifest with epigastric pain after meals. Tina Jones’s description of the timing of the pain and its relation with meals is not precise to adequate to clinically distinguish the type of PUD that he could have. The absence of nausea or vomiting cannot be used to rule out PUD. Peptic Ulcer disease can also ‘coexist’ with GERD. Therefore, further investigations would be required to rule out PUD in Tina Jones. Intake of alcoholic beverages and regular ingestion of carbonated drinks predisposes her to the development or progression of peptic ulcer disease and GERD.

  1. Pancreatitis:

Pain in the upper epigastrium could also be due to pancreatitis. This pain is also worsened by lying supine (Malik et al., 2020) and bending over just as reported by Tina Jones. Intake of alcohol places her at risk of developing pancreatitis. However, the amounts, duration, and type of alcohol intake that she described are not clear to decide on her risk of pancreatitis. Otherwise, assessment of exocrine pancreatic function can be done to rule out pancreatitis.

  1. Gastritis:

Gastritis and PUD present similarly because acid erosion in PUD also causes gastritis. Gastritis in absence of PUD can be deduced from the subjective description of risk factors by the patient. Intake of alcohol places her at risk of gastritis (Malik et al., 2020). Autoimmune gastritis being an autoimmune disease may also affect females more than males. Her gender is, therefore, a risk factor for the development of autoimmune gastritis. Ingestion of food may therefore worsen the pain due to irrigation of ulcers due to gastritis

  1. Non-ulcer Dyspepsia:

Non-ulcer dyspepsia also called functional dyspepsia, is a condition that is usually diagnosed through exclusion. The presence of pain in the epigastrium after meals is characteristic. However, this pain is also present in the above-described differential diagnoses. When there is no identifiable pathologic cause of the pain and gastric ulceration, a diagnosis of non-ulcer dyspepsia can be made (Madisch et al., 2018). The patients usually present with PUD-like symptoms reflux-like symptoms.

Plan

Diagnostics: no lab or clinical evaluations have been done. However, the following investigations may direct further care.

  • H. pylori test – serologic testing
  • Serum amylase and lipase
  • Esophagogastroduodenoscopy may be done after the fits therapy phase, described later, fails
  • Electrocardiography may be used to rule out the cardiac etiology of the pain.

Treatment: omeprazole 20mg PO OD for 8 weeks. Proton Pump Inhibitor (PPI) Therapy is the first-choice pharmacotherapy modality for GERD (Young et al., 2020). This medication would be appropriate for her because there are no alarm signs such as hematemesis, anemia, melena stool, recurrent vomiting, or weight loss. However, upper GI endoscopy may be indicated if the patient doesn’t improve with PPI therapy. Upper GI endoscopy would rule out other causes of reflux such as reflux esophagitis, eosinophilic esophagitis, Barret esophagus, and gastric malignancies.

Patient education: the patent would be educated about lifestyle modification to reduce her risk of progression of reflux symptoms. Weight loss would help reduce her risk of GERD and so would the dietary modification such as avoidance of spicy foods and high-fat foods (Sandhu & Fass, 2018). Moderation of her alcohol intake would reduce the risk of gastritis in the background of GERD.

The patient would be educated on the adverse effects of long-term use of omeprazole (Prilosec) such as bone fractures, macronutrient deficiencies, and bacterial infection of the bowels (Young et al., 2020). She would also be advised on avoidance of meals before about 2 to three hours before bedtime as this would reduce the risk of reflux. The use of enough pillows to elevate the head and the upper trunk would help in relieving regurgitation. Avoidance of carbonated beverages would also be useful in health maintenance.

Referral: the patent would be referred to a gastroenterologist in case she doesn’t improve with PPI therapy. Devilment of alarm signs aforementioned would warrant referral for upper GI endoscopy and gastroenterologist consultation.

Follow-up: Tina Jones would be seen again in the clinic in two weeks for reassessment and follow-up. If alarm signs are noticed before then, she would visit the clinic for reevaluation.

Tina Jones Gastrointestinal Assessment Soap Note References