SOAP NOTE: PEPTIC ULCER DISEASE DUE TO HELICOBACTER PYLORI
CHIEF COMPLAINT (C/C)
“I have epigastric pain, heartburn, bloating, and excessive release of gas. The epigastric pain and heartburn are severe when I am hungry and they go away when I eat some food.”
HISTORY OF PRESENT ILLNESS (HPI)
A 38-year-old Latino male patient has visited the clinic unaccompanied. His chief complaint is epigastric pain that occurs together with heartburn, bloating, and excessive release of gas. These symptoms started a year ago. Initially, the used to occur when the patient is hungry but their frequency have increased to about twice a day. According to the patient, the epigastric pain and heartburn are worsened with hunger but they resolve when he eats some food.
They are also triggered when he consumes, fruits, spicy foods, and some beverages such as fresh juice. The patient reports that he had a sprain of the ankle joint about a year ago and that he often uses non-steroidal anti-inflammatory drugs (NSAIDs) to relieve the pain which has never gone away completely. He denies using any other medications apart from NSAIDs.
PAST HISTORY
CHILDHOOD ILLNESSES:
Denies a history of measles, mumps, rubella, whooping cough, rheumatic fever, scarlet fever, or polio.
IMMUNIZATION:
Childhood vaccine Immunization
– Hepatitis B: 3/3
– Diphtheria, Tetanus, and Pertussis: 5/5
– Booster dose of TDAP 2018
– Hemophilus influenza type B: 4/4
– Pneumococcal conjugate: 4/4
– Inactivated Polio- virus- 4/4
– Measles, Mumps, Rubella: 2/2
-Influenza 01/22
COVID vaccine Completed 10/17/21, 02 /20/22.
ADULT ILLNESS: The patient had malaria last year. He was successfully treated at home without hospitalization because his symptoms did not require hospital admission. He also suffered a sprain on the ankle joint about 12 months ago. He was treated as an outpatient without hospitalization.
PSYCHIATRIC ILLNESS: Reports a history of alcohol use disorder, depression, and anxiety.
ACCIDENTS or INJURIES: Suffered a sprain on the ankle joint about 12 months ago when he was playing soccer.
OPERATIONS: Denies a history of surgery
ALLERGIES: No known drug or food allergies.
MEDICATIONS: Reports NSAIDs use.
COMPLIMENTARY TREATMENTS: None
FAMILY HISTORY: Father is alive and he is currently 70 years old. He is healthy without a serious medical diagnosis. Mother is 66 years old and has not been diagnosed with a serious health condition. The patient is the first born in a family of 2 children. His younger sister is healthy. The patient does not have any information regarding the cause of death of his maternal grandparents. His paternal grandmother has hypertension while his paternal grandfather is healthy.
SOCIAL HISTORY
Education: A diploma graduate
Occupation: Surveyor
Living situation: Lives with his family in a rental house
Denies a history of childhood asthma. Denies a history of hemoptysis, bronchitis, emphysema, pneumonia, tuberculosis, or pleurisy. Does not report TB or exposure to TB. Last physical check-up for pulmonary function was two years ago. Denies a history of pneumonia or a history of exposure to chemicals.
Physical activity: The patient engages in physical activity over the weekends by playing soccer. He decided to reduce the frequency of playing soccer since he suffering an ankle sprain.
CARDIAC: Denies chest pain, or palpitations. Denies paroxysmal nocturnal dyspnea. Does not report orthopnea, edema, palpitations, hypertension, or known heart disease. Denies rheumatic fever, heart murmurs, or pain in posterior calves.
GASTROINTESTINAL: Reports epigastric pain heartburn, bloating, and excessive release of gas. The epigastric pain and heartburn are severe when the patient is hungry and they go away when he eats some food. Consumption of fruits, spicy foods, and some beverages such as fresh juice triggers the epigastric pain and heartburn. Reports dyspepsia or indigestion. Reports getting full quickly whenever he consumes food.
PHYSICAL EXAMINATION
VITAL SIGNS: BP: 128/85 (sitting, automatic), P: 89, RR: 18, T: 36.5 Ht: 62 inches Wt: 172 lbs; BMI: 22.8.
GENERAL SURVEY: Alert and oriented to time, person, and place. No evidence of acute distress or fatigue. Well nourished. The patient’s appearance is appropriate for the stated age. Reports indigestion and nausea.
SKIN: Skin is smooth, warm, dry, and intact without rashes, or lesions. Nail beds are pink with no evidence of clubbing or cyanosis.
HEAD: The head is normocephalic and atraumatic. Hair is short. There