Comprehensive SOAP Note July 10 th , 2019 @ 1030 AM Patient Information : CJ is a pleasant, 27-year-old married, Caucasian male currently residing in Andalusia, Alabama. Insured by Blue Cross and Blue Shield of Alabama. Referral & Reliability : Self-referred and seems reliable. S – Subjective Data Chief Complaint : “I keep having heartburn after eating.” HPI: Location – Upper stomach, chest, and throat. Pain does not radiate. Quality – “Burning sensation.” Quantity/Severity – Discomfort from burning sensation is 4 on 0-10 pain scale. Timing – Sudden onset 2 weeks ago after eating Mexican food; reoccurring episodes 2-3 times weekly since initial episode after eating spicy or greasy foods; can last 2 hours or longer. Setting/Context – Patient believes “spicy Mexican food irritated his stomach triggering heartburn.” Aggravating or Relieving Factors – Spicy or greasy food, drinking soft drinks, and using smokeless tobacco worsen symptoms. Taking OTC Tums helps relieve symptoms. Self-Treatment – OTC Tums 750 mg, 2 tabs by mouth at the onset of symptoms; some relief after about 2 hours after taking Tums Past Medical, Family, or Social History related to CC/HP – Patient consumes fast food almost daily, drinks 3-4 caffeinated beverages daily, and uses 1 can smokeless tobacco daily. No pertinent family Hx assessed. PMHx: Childhood Illnesses – Chickenpox (1997). Denies other childhood illnesses. Major Adult Illnesses – Migraines (onset 2008) Controlled with medication – see listed below; idiopathic elevated liver enzymes (onset 2018). Denies other adult illnesses. Immunizations – Immunizations are “up to date from previous employment overseas.” Tdap 2018; HBV 2018; Pneumonia 2018; Influenza 2018; Polio 2018; Pertussis 2016; Diphtheria 2018; MMR 2018; Denies having HPV vac. Health Maintenance Screenings – TB skin test 2018, stool for occult blood 2018, eye exam 2018, hearing test 2018, prostate exam 2018, cholesterol screening 2018, hepatic panel 2018 Hospitalizations/Surgeries o 2014 observation admit for “separated clavicle from a snowboarding accident.” o 2011 observation admit for “arm injury from wakeboarding accident.” o 2009 surgical admit for “ACL repair of the left knee.” Injuries/Accidents – See above. Denies other injuries/accidents.
Current Medications o Maxalt 10mg 1 tab PO PRN migraine o Tums 750mg 2 tabs PO PRN heartburn Allergies – No known food, drug, environmental, insect, or latex allergies. FamHx: Patient unable to provide information on maternal grandparents. 73-year-old, living paternal grandfather with Hx of bladder cancer, hypertension, osteoarthritis, and smokes cigarettes. Paternal grandmother deceased at 68-years-old due to metastatic ovarian cancer. 55- year-old, living father with high cholesterol, elevated liver enzymes, and uses smokeless tobacco.
- Summer '19
- Gastroesophageal reflux disease