Female with Burning Feeling in Stomach Soap Note

SOAP NOTE EXAMPLE

The following is an example of a Focused Exam SOAP note. Select the systems for the ROS and PE that are appropriate to gather the data needed (subjective and objective) to arrive at a diagnosis, or differential.  1) Please note the distinction between (S)ubjective and (O)bjective findings – and which data belongs in which heading.   2) Then provide your primary diagnosis with any differentials if you cannot conclude a single diagnosis.  3) Provide a treatment plan.

Female with Burning Feeling in Stomach Soap Note

ID:  52 Y.O white female who works part time in a flower shop

Informant: (note this if someone other than the patient provides the information)

S:

CC: “Burning feeling in stomach” x 2 months

HPI: Burning in epigastric area that started 2 mos. ago. Discomfort occurs 3-4 days of the week, mainly at night, 7-8 in severity. Burning takes all night to go away, at times making it hard to sleep. Has had indigestion previously but states it is not the same feeling. Associated with nausea and bloating. Denies vomiting.  Spicy food makes discomfort worse. Bowel movements are daily, soft, formed, and brown in color. Tums and Mylanta help occasionally.

Past Medical History: Anxiety

Past Surgical History: 1989 Cholecystectomy

Family History: Brother: 54 – Hx of GERD

Mother: 72 – Hx of “bleeding ulcer @ age 65; Hx of Alcoholism

Habits: Denies smoking, alcohol or drug use, exercises 3x/week

Medications: Lexapro 10mg daily

Allergies: NKDA, no environmental, food

ROS:   General Denies recent weight changes, fever, fatigue or recent travel.  HEENT: Denies difficulty chewing or swallowing Resp: Denies cough or SOB. CV: Denies chest pain.  GI  Denies vomiting, chronic indigestion, belching, abdominal cramping, appetite changes, jaundice, diarrhea, constipation, flatulence, rectal pain, hemorrhoids, or rectal bleeding.  Denies changes in bowel habits.

O:

T-37.8 P-88     R-20    BP-126/72       WT-188 lbs     HT-5’4”

General:  This an obese Caucasian female in no apparent distress.  HEENT: Eyes: Sclera are white. Throat is pink, without lesions. Lungs: Full excursion. Lungs are resonant to percussion, clear to auscultation bilat. Heart: PMI is 2 cm in the 4th ICS at the MCL. Heart rate is regular. There are no murmurs. PV: Extremities are pink, radial, d. pedis and p. tibial pulses are +2. Capillary refill is 2 sec. Abdomen: Is protuberant, skin without scars or lesions, flesh-tone, Bowel sounds are active x 4 quadrants. No bruits, no rubs.  Liver span – 9 cm @MCL. No splenomegaly No rigidity or guarding.  Tender over the epigastrium with light palpation. No masses are palpated. Murphy’s sign is negative.

A: GERD – Primary

Gastritis  & Peptic Ulcer Disease –  Differentials

PLAN

  • Pepcid (famotidine) 20 mg po q 12 hours
  • Avoid foods that make symptoms worse; eliminate caffeine and mints; eat small frequent meals; avoid eating within 3 hours of bed; elevate the head of the bed 8 inches
  • Seek medical attention if you experience worsening symptoms such as vomiting, hematemesis, or melena
  • Return visit in 4 weeks to re-evaluate treatment

Focused SOAP Note Sample 2

Patient details:

Name: AC

Age: 14 years

Ethnicity: Caucasian

Gender: Female

Subjective

Chief Complaints: “AC has been acting bizarre since the last hospitalization. She has been trembling more often in the recent four days”

History of Presenting Illness: AC is a 14-year-old white female who was accompanied by the mother to the clinic for psychiatric evaluation and treatment. The mother reports that AC has been washing her hands more frequently than required during the day and appears withdrawn from her friends who she used to play with and watch movies together.

Her behavior after she was treated by the family physician for gastroenteritis one month ago and recovered. However, the primary care physician advised her to wash her hands usually before and after meals and after visiting the toilet. Unfortunately, the mother reported that AC is overdoing the practice and washes her hands without reason even before going to bed.

A week ago, when AC was asked by the mother to accompany her to the hospital to hospital, she appeared sweaty and trembling but couldn’t state the reasons for her panic. She has developed a dislike for the primary care physician who treated her for gastroenteritis and always avoids him whenever he visits. Her mother summoned to the school to discuss AC’s performance that appeared to have dropped abruptly from the previous assessments. AC denies occasional nightmares but reported dreaming about having a stomach upset once in the last two weeks. The mother also denied sleep difficulties in AC as she also confirmed no insomnia.

Past Psychiatric History: AC is not on any treatment for any condition. She has never been diagnosed with any psychiatric illness.

Family Psychiatric / Substance Use History: no family member uses illicit drugs or takes alcohol. There’s no history of mental illnesses in the family. There’s is tobacco smoker in the family.

Medical History:

Current medications: currently, AC is not on any medications

Allergies: she has no known allergies to any drugs or food

Reproductive: her menarche was five months ago. Her menses are irregular and last averagely for two to three days. She has experienced two months of consecutive amenorrhea. She is not sexually active and has not yet debuted into sexual activity.

Review of Systems

General: no fever, weight loss, or night sweats

HEENT: no headache, blurry vision, loss of hearing, anosmia, or sore throat

Skin: no rashes, abnormal pigmentation, itchiness, or acne

Cardiovascular: no chest tightness, pain, or fullness, no edema of the extremities or distension of neck vessels

Respiratory: no chest pain, cough, difficulty in breathing,  or shortness of breath

Gastrointestinal: no difficulties in swallowing, loss of appetite, burping, constipation, diarrhea, or bloating

Genitourinary: no vulval itchiness, vaginal discharge, abnormal bleeding, or urinary frequency. No hematuria or dysuria

Neurological: no paralysis, ataxia, weakness, or tics

Musculoskeletal: no muscle pain

Hematologic: no anemia, abnormally prolonged bleeding, fatigue, or history of venous thromboembolism

Lymphatic: no edema of the extremities, no history of weight gain or angioedema

Objective

Physical Examination: general examinations showed no jaundice, dehydration, or respiratory distress

Diagnostic Results: electrolyte assay showed no derangement in potassium, sodium, calcium, creatinine, or urea levels. Liver function was essentially normal

Vital Signs: 108/76 mmHg, 98.6⁰F, 26 breaths per minute, 98 heartbeats per minute, 97% oxygen saturation in the room air, BMI 23.5

Assessment

Mental State Examination: AC is a 14-year-old Caucasian female who looks her stated age. She well-kempt, her attire is neat and her hair is neatly held together at the back. She appears jittery and holds her hands together. Her palms are dump and appear sweaty. Mild hand tremors were seen at the beginning on her hands. She rarely maintains eye contact and prefers looking down or through the window. She is well oriented in all spheres. Her speech is adequate in volume and rate but appears to be breaking at some point when she discusses her last encounter with the primary care physician.

She states that she likes washing her hands because she hates germs which she thinks are everywhere and in everyone. She thus avoids people and handshakes. She appears suspicious and anxious during the examination. Her thought process is adequate but there are overvalued ideas because she was obsessed with germs. Her insights are fair and her judgment is appropriate. No delusions or hallucinations were reported. Her mood is depressed and her affect is appropriate.

Differential Diagnoses: the primary diagnosis is an obsessive-compulsive disorder. Differential diagnosis includes generalized anxiety disorder, traumatic stress disorder, and depressive disorders. The patient meets the DSM 5 criteria for diagnosis of obsessive-compulsive disorder (American Psychiatric Association, 2013). This is different from an obsessive personality disorder. In this patient, the obsession is with germs and the compulsion is to wash her hands. Before the visit to the primary care physician, the patient was behaviorally normal per the mother’s reports.

Post-Traumatic Stress Disorder (PTSD) is also likely in this patient (Coimbra et al., 2020). The incident with the primary care physician might be emotionally traumatizing and might have sequelae on her. This is evident when she appears anxious and her voice breaks when she was asked about that encounter. Generalized Anxiety Disorder is the second differential diagnosis because of instances of reported and objectively witnessed episodes of anxiety (Munir & Takov, 2021).

Her anxiety would be associated with different items such as the sight of the clinician, the new environment among other triggers. The last priority diagnosis is depressive disorder because the patient also showed features of depressed mood during a mental state assessment. However, this could be associated with obsessive-compulsive disorder (American Psychiatric Association, 2013).

Plan

Treatment, Follow-up, and Patient Education: the patient was proscribed Prozac (fluoxetine) 20mg/day. Fluoxetine is a selective serotonin reuptake inhibitor that is used as an on-label treatment for OCD in children (Maneeton et al., 2020). He was also registered into a psychotherapy program where group cognitive-behavioral therapy (CBT) was offered.

The patient is to be seen again in 2 weeks in the clinic. The mother was educated on the need to ensure compliance with the prescription and encourage the whole family to support emotionally appropriately the patient. The risk of suicide in the patient was low but the mother was advised to call the hospital when symptoms of violence, aggression, or suicide are noticed. In the meantime, she was to follow up with the psychologist to ensure the CBT sessions are offered.

Reflection Notes

The patient’s case presented mixed diagnoses that required closed monitoring. Ethically, the case was handled appropriately to the best of my knowledge. The prescription was on-label and the risk of self-harm was assessed. The consent treatment was implied by their visit to the clinic. The mother was informed about the treatment and offered oral consent. The patient is a minor but to some level assented to the treatment.

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 (R)) (5th ed.). American Psychiatric Association Publishing.
  • Coimbra, B. M., Yeh, M., D’Elia, A. T., Maciel, M. R., Carvalho, C. M., Milani, A. C., Mozzambani, A., Juruena, M., Belangero, S. I., Jackowski, A. P., Poyares, D., Mello, A. F., & Mello, M. F. (2020). Posttraumatic stress disorder and neuroprogression in women following sexual assault: Protocol for a randomized clinical trial evaluating allostatic load and aging process acceleration. JMIR Research Protocols9(11), e19162. https://doi.org/10.2196/19162
  • Maneeton, N., Maneeton, B., Karawekpanyawong, N., Woottiluk, P., Putthisri, S., & Srisurapanon, M. (2020). Fluoxetine in the acute treatment of children and adolescents with obsessive-compulsive disorder: a systematic review and meta-analysis. Nordic Journal of Psychiatry74(7), 461–469. https://doi.org/10.1080/08039488.2020.1744037
  • Munir, S., & Takov, V. (2021). Generalized anxiety disorder. In StatPearls. StatPearls Publishing.