SOAP Note

Patient Initials: S.P. Age: 42 Gender: Female

SUBJECTIVE DATA

Chief Complaint (CC): "I've been having stomach discomfort and problems for the past few weeks."

History of Present Illness (HPI): 42-year-old Caucasian female presents with complaints of stomach discomfort for the last 3-4 weeks.

Location: Upper abdominal region

Quality: Burning sensation

Quantity or severity: Moderate to severe

Timing: Began gradually about 3-4 weeks ago and has been persistent since then

Setting: Symptoms worsen post meals

Factors: Spicy foods seem to exacerbate discomfort, no relief noted with over-the-counter antacids

Associated manifestations: Reports occasional nausea, bloating, and belching

Medications: OTC antacids as needed

Allergies: No known drug allergies

Past Medical History (PMH): Hypertension, Childhood Measles

Past Surgical History (PSH): Tonsillectomy at age 7

Sexual/Reproductive History: G2P2, Menarche at age 12, regular menstrual cycles, uses birth control pills

Personal/Social History: Non-smoker, occasional alcohol use (1-2 glasses of wine/week), no illicit drug use. Works as an accountant, mostly sedentary lifestyle.

Immunization History: Flu shot last year, Tdap 10 years ago

Significant Family History: Father had peptic ulcer disease, mother has hypertension

Lifestyle: Lives with husband and two children, has a moderate level of stress due to work, has a support system in place

Review of Systems

General: No recent weight changes, no fatigue

HEENT: Normal, no issues

Respiratory: Clear, no shortness of breath or cough

Cardiovascular/Peripheral Vascular: Regular rhythm

Gastrointestinal: As described in HPI

Genitourinary: Normal, no complaints

Musculoskeletal: No joint or muscle pains

Psychiatric: No anxiety, depression, or other psychiatric symptoms

Neurological: Alert, oriented x3

Skin: No rashes, sores, or other abnormalities

OBJECTIVE DATA

Physical Exam

Vital signs: BP 130/85, HR 75, RR 16, Temp 98.6F, Weight 150lbs, BMI 24

General: Well-groomed, alert, oriented, in no distress

HEENT: PERRL, EOMI, no oropharyngeal erythema or exudate

Chest/Lungs: Clear to auscultation bilaterally

Heart/Peripheral Vascular: S1 and S2 normal, no murmurs, regular rhythm, peripheral pulses intact

Abdomen: Soft, non-tender, non-distended, positive bowel sounds, mild tenderness in the epigastric region

Genital/Rectal: Deferred

Musculoskeletal: Full range of motion, no pain or swelling

Neurological: Alert, cranial nerves II-XII intact, no focal deficits

Skin: Warm, dry, no rashes

ASSESSMENT

The primary diagnosis for this patient is H. pylori gastritis, which is supported by a positive stool sample indicating H. pylori presence (Goud et al., 2019). Guidelines emphasize the importance of testing in patients manifesting chronic gastritis symptoms (Shah et al., 2021).

Differential diagnoses include:

1. Gastroesophageal reflux disease (GERD): Given the patient's presentation with a burning sensation, bloating, and belching, GERD is a plausible diagnosis (Wilkinson et al., 2019). GERD is typically a common consideration in the context of upper gastrointestinal symptoms.

2. Peptic ulcer disease (PUD): Given her family history and epigastric pain, PUD remains a possibility (Alzharani et al., 2020). An endoscopic examination might offer insights into the presence of any ulcers, further delineating the diagnosis.

3. H. pylori gastritis: The patient's symptoms, and what could be described as chronic episodes, combined with the lab results, could also justify this diagnosis (Hall & Appelman, 2019).

In addition to the present complaints, it would be important to account for her previous diagnosis of...…eradication, for example, would be effective from a clinical standpoint, but it does come with potential side effectsso this is something that would have to be talked about with the patient absolutely. Taking additional time to go into these potential side effects is helpful for the doctor-patient relationship because then the patient fully understands them, and it gives them an opportunity to voice their concerns, which is something that ought to be prioritized in future encounters. This would help with adherence to treatment, in my opinion, and also in building trust and establishing a solid relationship with the patient.

The experience also reinforced the necessity of evidence-based medicine in clinical practice. My preceptor's commitment to an evidence-driven approach has been, as always, a good reminder of its value. Evidence directs us so that our decisions are rooted in the best available information, and so that we are offering the highest standard of care. It is an approach that seamlessly ties into a holistic model of patient care, where the patient is viewed as a person and not just as a set of symptoms. Every patient is a unique individual with their own needs, experiences, and background of family health. This is a holistic perspective, which is something that has been emphasized throughout, and it reiterates the imperative of treating not just the disease, but the individual as a whole. I am certain that keeping this…