Comprehensive SOAP Note July 10th, 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. 53-year-old, living mother with hypertension. 29-year-old, living wife with congenital heart disease, heart murmur, and hypothyroid. 2-year-old, living daughter with reflux as an infant. Patient denies FamHx of CAD, stroke, DM, TB, asthma or another lung disease, renal disease, seizure disorders, mental illness, suicide, breast cancer, colon cancer, GERD, and other genetically transmitted diseases. Family history depicted below in genogram (Bickley, 2017) [Show More]
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