ANSWER
Subject of SOAP Note: The patient is a male patient, age 21, who has been diagnosed with GERD without esophagitis (K21.9). He shows in for a follow-up appointment to talk about the management at the moment and the test results. The patient describes having a burning feeling in the abdomen, usually after eating, and that occasionally gets worse at night or while they are sleeping. He states that a gastroenterologist examined him and ordered a negative H. pylori test. For three months, omeprazole 40 mg PO daily and sucralfate have been prescribed to him. It was advised to make dietary and lifestyle adjustments.
Goal:
Vital signs are within typical ranges.
Physical Examination:
Soft, non-tender, and free of distension is the abdomen. typical bowel noises. No masses or hepatosplenomegaly were seen.
Diagnostics: Ultrasound of the abdomen is within normal bounds.
Evaluation:
GERD (K21.9) without esophagitis.
Plan:
Present-day Drugs:
Keep taking 40 mg PO of omeprazole every day.
As directed by the gastroenterologist, keep taking sucralfate.
Changes in Lifestyle:
Steer clear of trigger foods like fatty, acidic, or spicy meals.
Steer clear of late-night eating and consume smaller meals more regularly.
To lessen symptoms during the night, raise the head of the bed.
After eating, avoid lying down for at least two hours.
Limit alcohol, cigarettes, and caffeine (if any).
Learning:
examined food and lifestyle modifications in detail.
on following prescription drug regimens and making necessary adjustments.
discussed signs including extreme stomach discomfort, inadvertent weight loss, or trouble swallowing that call for prompt follow-up.
Follow-up:
Maintain your current course of treatment.
If symptoms worsen or continue after taking medicine and changing one’s lifestyle, follow up in three months or sooner.
Endoscopy will be considered by gastroenterology if symptoms do not improve after three months.
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QUESTION
Patient is a 21 y/o male with GERD without esophagitis, who came to discuss test results, abdominal US was within normal limits, he indicates was seen by Gastroenterologist, who ordered H pylori test which was negative, he also ordered Omeprazole 40gm PO + Sucralfate for 3 months, and will consider endoscopy if symptoms to not improve. Lifestyle modification and dietary changes was recommended, patient education provided. We will follow up as needed. Patient report has been experiencing A burning sensation in the abdomen often after eating, which sometimes get worse at night or when lying down.
Diagnosis: K21.9