Gastrointestinal SOAP CC: “I’m been very nauseated lately. My stomach burns after I eat everythi. Question
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Asked by sfatimata1987
Gastrointestinal SOAP
CC: “I’m been very nauseated lately. My stomach burns after I eat everything.
HPI: RB is a 59 year old white female, she presents to her local hospital’s emergency department complaining of nausea (no vomiting), lethargy, and epigastric pain described as “burning” off and on during the day, but especially after eating. Was seen in an urgent care 7 weeks ago with similar GI symptoms and was treated for an H.pylori infection with amoxicillin, clarithromycin, pantoprazole triple therapy at the time. Patient reports full adherence to the 14 day regimen. She has recently moved to this area from another state and has yet to establish a primary care provider. She rarely saw her prior primary care physical in the past, although she had visited her for increasing left-knee pain that was ascribed to osteoarthritis. The patient does not like to take “artificial” medications and refused any treatment for her osteoarthritis. She denies any melena, BRBPR, hematemesis, CP or any other symptom
PHM: Osteoarthritis of left knee, HTN, Hyperlipidemia, s/p atherosclerotic CVS
FH: Father had a history of HTN and hyperlipidemia but died of colon cancer at age 72. Mother is alive and well at age 74. She has no siblings
SH: The patient is married and lives with her second husband. She has one son from a previous marriage, age 18. She works as a certified public accountant. She is generally uncomfortable with taking medications and feels that natural medicines are preferable to “artificial pills” (her words). Social drinker; + tobacco, 0.5 pack per day x35 years- quit 4/2016, + marijuana, smokes approx. 1 joint every 2-3 weeks for knee pain
Allergies/Intolerances: Adhesive tape (rash), Fluoroquinolones (peripheral neuropathy)
Meds:
Clopidogrel 75mg daily
Diltiazem CD 180mg daily
Red Yeast Rice 1200mg BID
Willow Bark Extract 800mg BID for knee pain
Glucosamine + Chondroitin 3 caps daily
Antioxidant Vitamin A,C,E and Selenium 1 cap daily
Amoxicillin 1g BID (completed 5 weeks ago)
Clarithromycin 500mg BID (completed 5 weeks ago)
Pantoprazole 40mg BID (completed 5 weeks ago)
Vaccines up to date
Review of Systems: Nausea and epigastric pain as listed above, (-) changes in bowel habit or change in color/consistency of stool; (+) anorexia, (-) tinnitus, vertigo, or infections, (+) left knee pain, especially when kneeling or first thing in the morning
Physical Examination: Well-appearing white female with minimal distress
Vital Signs: Bp 138/84 mm Hg, P 61, RR 11, T 37.2C, weight 165lb, Ht: 70 inches
Pain 2/10 in knees this morning, epigastric pain 4/10
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HEALTH SCIENCE
NURSING
NURS 645
Gastrointestinal SOAP CC: “I’m been very nauseated lately. My stomach burns after I eat everythi
