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SOAP Note Chest Pain

SOAP Note Chest Pain

Assignment

Please provide a narrative of information you feel is appropriate to understanding of the care of the patient especially if this is a follow-up visit. Discuss the disease process and health risks that are specific to the patient/culture/ethnicity. Discuss the guideline/s you utilized as the basis to provide care. Are there home care issues that may impact on this patient*

CC” Chest pain”.

HPI: I have visited this 82-year -old patient today. The patient reports that he had chest pain started one week ago, and each time the pain happens, an episode of compression occurs at night and forces him to wake up. However, no episode has been reported over the last two nights. The latest episode of pain improved when he positioned himself and propped up on a pillow, and this relieved the pain. Over the last few days, he has been eating large night meals than usual. He reports no cases of palpitation, SOB, or diaphoresis. Regarding the chronic obstructive pulmonary disease, he has been experiencing episodes of shortness of breath associated with an intense activity since the time he was given new inhalers.

However, he rarely coughs and reports to walk a flight of stairs without experiencing shortness of breath. He has a past medical history of chronic obstructive pulmonary disease. He reports no history of hypertension.

SOAP Note Chest Pain Example Narrative Paper

Assignment One: Gastroesophageal Reflux Disease

1. Subjective Data (S)

Chief complaint: The chief complaint is chest pain

History of Present Illness:        

The patient presents with chest pain that began about a week ago. Every time the chest pain occurs, there is a compression episode that occurs during the night, and he is forced to stay awake. But, no incident has happened in the last two nights.  He describes the pain as burning and gnawing with a rating of 8/10 at the onset, but now it is 2/10. The most recent episode improved when he is sitting upright and propped up on his pillow, and the pain was relieved. The pain is alleviated by sleeping, antacids, and Pepcid AC. No pain radiation is reported. In the last few days, the patient relates that the pain commenced after eating large meals at night. However, he is not sure whether the pain can be associated with the food. Other factors that precipitate the symptoms are reclining after eating and wearing constrictive clothing. The patient has reported no cases of shortness of breath, palpitation, or diaphoresis.

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Review of Systems

Constitutionals: Patient states that he is slightly anxious, but denies difficulty breathing

HEENT: Denies headache, fever, malaise, and chills; No ear pain, hearing loss, fullness, and popping; No eye pain, blurry vision, pain, drainage, and itching; No nose drainage, allergies, sinus pressure and loss of sense of smell; No sore throat, difficulty swallowing, loss of taste, and bleeding gums; No difficulty chewing, gum pain, and tooth pain.

Neck: Denies neck pain and stiffness
Cardiovascular: No chest pain, pressure, orthopnea, dizziness, palpitation, or syncope.
Respiratory: No shortness of breath, coughing, wheezing, production of sputum

Gastrointestinal: Positive for dysphagia. Denies nausea, abdominal pain, vomiting, indigestion, constipation, reflux, melena, diarrhea, no changes in bowel habits, and rectal bleeding.

Genitourinary: Positive for urine retention, negative for pressure, burning sensation, dysuria, frequency, polyuria, hematuria, offensive urine odor, or flank pain.
Musculoskeletal: Reports of weakness. Denies muscle/joints stiffness, swelling, muscle cramps, deformities, articular pain, ROM limitations.
Integumentary: No rash, new moles, acne, breakdown, itching, abrasion, injuries, and any other skin change.
Neurological:  Denies history of seizures, memory loss, tremors, imbalance, weaknesses, numbness, paralysis, disorientation, tingling, speech disorder, or involuntary movement.
Psychiatric: Denies depression, psychiatry disorders, anxiety, hallucinations, panic, mood changes, memory disturbance, or nervousness
Endocrine: No thyroid disorder, cold or heat intolerances, excessive sweating, or neuropathy.

Past Medical History

No previous history of abdominal pain and hypertension. He has a history of COPD. He reports that he rarely coughs and walks a flight of stairs without experiencing SOB. Since he was given inhalers, he has been experiencing SOB episodes associated with the intensive activity. Unspecified severe protein-calorie malnutrition, unspecified UTI, urine retention

Past Surgical History: Hip Surgery

Family History:

Father: Hypertension & Myeloma Multiple.

Mother: Chronic Obstructive Pulmonary Disease

Social History:

The patient does not drink alcohol, smokes two ppd, and does not have any regular exercise routine. He is retired and lives alone. His only family is his son, who visits two times weekly.

Allergies: No allergies

2. Objective Data (O)

Physical Examination

General Appearance: Patient appears slightly anxious

Vitals: BP: 115/62, HR: 76, RR: 17, Temp: 98.2, Weight: 126, height: 5’5’’2, SO2: 95%.

Lungs: Distinct sound, Negative wheezing when breathing

Cardiovascular: Negative murmurs, Negative S1 and S2, and regular rate and rhythm

Abdominal: Negative tenderness to palpations, normal bowel sound

3. Assessment/Diagnosis (A)

The key differential diagnosis is

  1. Gastroesophageal reflux disease
  2. Peptic Ulcer Disease
  3. Gallbladder disease
  4. Chest pain

The most likely diagnosis is GERD (Gastroesophageal reflux disease): The diagnosis is made by history alone. The patient presented with a burning kind of pain (mild heartburn) after eating a large meal at night, dysphagia, epigastric pain upon palpation. The patient denies nausea, vomiting, constipation, and diarrhea. The physical examination revealed stool positive for occult blood on rectal exam and pain restricted to the epigastric area.

Peptic Ulcer Disease: The PUD disease cannot be considered since the presentation of the pain is consistent as the burning pain is in the epigastrium occurring hours after large meals. However, the sudden onset once a day is consistent with GERD. Unlike GERD, PUD typically produces tenderness on palpation and epigastric pain. The pattern that differentiates GERD from PUD is the heartburn from peptic ulcer disease is relieved by ingesting food. In case the symptoms worsen soon after eating.

Gallbladder Disease: The patient presents with right subcostal pain and epigastric. Gallbladder disease is ruled out due to nausea and vomiting associated with cholecystitis and cholelithiasis, which does not occur in gastric reflux.

Chest Pain: Occasionally, GERD could be presented with chest pain. The chest pain diagnosis is ruled out since the practitioner differentiated between symptoms of cardiac origin and GERD. The history of the patient did not reveal that the pain is of the cardiac origin or connected with exercise and relieved by resting and nitrates. The patient’s history did not reveal radiation of pain to jaw, arm, and neck, dyspnea, diaphoresis, and syncope.

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4. Plan (P)

Patient and Family Teaching

The goal of GERD management is rapidly eliminating or reducing symptoms, preventing symptoms related to meal or exercise, and cost-effectively preventing complications. The emphasis of management is on the education of the patient on lifestyle modifications as the first line of treatment. This will consist of the elevation of the head of the patient’s bed 6 inches and avoidance of fatty, large meals, and some foods like chocolate, peppermint, tomatoes, caffeine, onion, citrus, and garlic. The patient is also instructed to shun recumbency and sleeping for 2 hours 3 hours after meals to avoid heartburn. He should also avoid snacks during bedtime. Also, some medications should be avoided as they can affect the LES pressure, including nitrates, calcium channel blockers, alpha-adrenergic agonists, beta-blockers, theophylline, and some types of sedatives.

Treatment Plan

The guidelines for GERD treatment proposed by the Agency for Healthcare Research and Quality comprise the “step-up” and “step-down” approaches. The pharmacological interventions can be used when the lifestyle modifications and diet are ineffective in controlling the GERD symptoms; thus, the treatment can be “stepped up” to the use of medications. In cases where the patient has mild symptoms with no non-erosion reflux, then the first step-up is the use of H2-RAs for about four weeks. They include nizatidine 150 mg twice daily (Axid), cimetidine 800 milligrams twice daily (Tagamet), famotidine 20 milligrams twice daily (Pepcid), and ranitidine 150 milligrams twice daily (Zantac). The medications are available over the counter and prescription dosages. In case there is no improvement, then the proton pump inhibitors (PPI) can be used in dosages that eliminate symptoms effectively. Another alternate treatment plan is beginning treatment with proton pump inhibitors at a higher dose and “step down” the treatment to the lowermost dosage that suppresses the acid secretion effectively. The PPIs include omeprazoleg 20 mg, lansoprazole 30mg, rabeprazole 20 mg, and pantoprazole 40mg take once daily 30 minutes before breakfast. It is recommended to use an 8-week course of treatment to provide adequate control of the heartburn. Nonetheless, the most cost-effective treatment approach is either the patient-directed or the “on demand” approach, whereby the patient uses the medications as needed. If both regimens are ineffective, the patient ought to be referred to the gastroenterologist. Patients with a history of self-medication for a length of time might develop erosive esophagitis and require aggressive treatment.

Research Article Critique

There are emerging models in the pathophysiology of GERD, and the continuous technological advances in both diagnosis and management necessitate the periodic reviews and updates of the existing clinical guidelines, official statements, and recommendations from the renowned academicians globally. The Asociación Mexicana de Gastroenterología, in conjunction with national experts, analyzed the latest scientific evidence and formulated practical recommendations that offer guidance and expedite the diagnosis processes and treatment plans of the GERD patients effectively. The article includes figures, algorithms, and tables for convenience during consultations, along with valid opinions on the management of GERD within sensitive classes of the population, like older adults and pregnant women.

Billing

The billing code is ICD-10-CM K21.9 that is grouped in the Diagnostic Related Group (MS-DRG v37.0). The K21. 9 is the billable ICD code used in specifying the diagnosis of GERD with no esophagitis.

References

Bickley, L. S., Szilagyi, P. G., In Hoffman, R. M., & Bates, B. (2017).¬†Bates’ pocket guide to physical examination and history taking. Philadelphia: Lippincott Williams & Wilkins.

Cornett, L. P. (2016). Gastroesophageal Reflux Disease (GERD). Hauppauge: Nova Science Publishers, Inc.

Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing Рan interprofessional approach. Philadelphia, PA: F.A. Davis Company.

Huerta-Iga, F., Bielsa-FernaŐĀndez, M. V., Remes-Troche, J. M., Valdovinos-DiŐĀaz, M. A., & Tamayo-de, C. J. L. (October 01, 2016). Diagnosis and treatment of gastroesophageal reflux disease: recommendations of the AsociacioŐĀn Mexicana de GastroenterologiŐĀa.¬†Revista De GastroenterologiŐĀa De Mexico (English Edition),¬†81,¬†4, 208-222. Retrieved from https://www.sciencedirect.com/science/article/pii/S2255534X16300482

Marmo, A. S. (2014). Appendicitis: Risk factors, management strategies, and clinical implications. New York: Nova Biomedical.

Myrick, K. M., Karosas, L. M., Smeltzer, S., & Karosas, L. P. (2021). Advanced Health Assessment and Differential Diagnosis: Essentials for Clinical Practice. New York: Springer Publishing Company

Seller, R. H., & Symons, A. B. (2017). Differential Diagnosis of Common Complaints. Philadelphia, Pa, Elsevier/Saunders.

Tracy, M. F. (2019). Advanced practice nursing: An integrative approach. St. Louis, Missouri: Elsevier Saunders.

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