Soap Note Assigment

Patient counsel to entire the soap music. fascinate see attachment  39-year-old Virile succeeding a while epigastric abstinence Chief Compliant: "I've been having this abdominal abstinence, and it fitting seems affect it won't go far. It established probably a year ago. It used to supervene a few times a week, now it hurts entire day.” History of Bestow Illness: Mr. Rodriguez is a 39-year-old virile that newly immigrated to the United States from Dominican Republic. He complains of epigastric abstinence that began almost one year ago. He describes the abstinence as “burning” and occurring daily. He states that the abstinence casually worsens succeeding a while eating and casually it betters. He states that balmy foods construct the abstinence worsen. He admits to weekly NSAID experiment and drinking 3-4 alcoholic beverages a week. He surrender smoking 6 months ago. He drinks an herbal tea but does not experiment any deliverance or fluctuate in the concomitants. He denies any fervor, chills, loathing, hematemesis, hematochezia, or melena. PMH/Medical/Surgical History: No narrative of gastrointestinal problems in the elapsed. No narrative of surgery. No notorious garbage allergies. Medications: Takes ibuprofen “almost daily” for aches and abstinences associated succeeding a while working. Drinks herbal tea meant to better GI concomitants. Significant Nobility History: Unrepining states nobility narrative of feeling malady. Father had hypertension and his mother had diabetes.  Social History: Unrepining denies smoking. Unrepining states that he surrender smoking 6 months ago. Unrepining states that he drinks 3-4 beers weekly.  No unfair garbages.  Review of Symptoms:  GENERAL:  39-year-old Spanish plainive unrepining. Language note-maker bestow. Unrepining is brisk and oriented. Afebrile. Unrepining denies new, secret power dropping, fervor, chills, decrepitude or harass. HEENT:  Denies muddiness, fluctuate in expectation, nose, or ear problems. Denies animated throat.    SKIN:  No fluctuate in skin, hair or nails.  CARDIOVASCULAR:  Regular feeling trounce and rhythm. S1, S2, no murmurs, rubs, or gallops. RESPIRATORY:  clear to auscultation. GASTROINTESTINAL:  Soft, absolute, non-distended. Normoactive bowel sounds heard in lewd quadrants. Soft, non-distended, succeeding a while minimal epigastric humanity on subterranean palpation succeeding a whileout reverbeblame humanity or compensating, no hepatosplenomegaly, and no hernia or masses. GENITOURINARY: Denies problems succeeding a while urination.   NEUROLOGICAL:  No muddiness, dizziness, syncope, paralysis, ataxia, callousness or tingling in the extremities. No fluctuate in bowel or bladder curb. MUSCULOSKELETAL:  Alert & oriented x3. Denies muscle, tail abstinence, elbow abstinence or cacophony. HEMATOLOGIC:  Denies anemia, bleeding or bruising. LYMPHATICS:  No copious nodes. Denies narrative of splenectomy. PSYCHIATRIC:  Denies narrative of hollow or trouble. Unrepining does plain moment encircling paying for medications and flourish up visits due to failure of protection.  ENDOCRINOLOGIC:  Denies excretion, delibeblame or excitement intolerance. Denies polyuria or polydipsia.. Objective Data:  Temperature: 98.5 Fahrenheit Heart trounce: 78 beats/minute, regular Respiratory trounce: 16 breaths/minute Blood pressure: 133/82 mmHg Body Mass Index: 24.8 kg/m2- This BMI is succeeding a whilein ordinary rank according to the National Heart, Lung, and Blood Institute (2017).  Physical Assessment Findings: Unrepining is brisk, oriented and is cooperative.  HEENT:  PERRLA, no nystagmus musicd. Tympanic membranes are raise. External parley canals are ordinary. Oral pharynx is ordinary succeeding a whileout erythema or exudate. Tongue and gums are ordinary. Lymph Nodes:  Non-palpable Carotids: correspondent bilaterally 2+ Lungs:  clear to auscultation Heart:  Regular trounce and rhythm ordinary S1 and S2. Abdomen:  soft, non-tender, non-distended, no masses.  Genital/Pelvic:  unremarkable Extremities/Pulses:  ordinary pulse bilaterally Neurologic:  A&Ox3, cranial nerves raise Laboratory and Diagnostic Testing: Fecal Occult Blood Testing: negative Heliobacter Pylori (H. pylori) serology ordeal: Positive CBC succeeding a while differential to ordeal for other stipulations such as anemia or pancreatitis.  Upper GI endoscopy: can acceleration to hinder for loss to the integument of the stomach and to administration out malignancies (National Institutes of Health [NIH], 2017) Upper GI Series: Commonly used in the elapsed to diagnose peptic abscesss thus-far this ordeal can misunderstand smaller abscesss and does not assign for plain tenor of the abscess (American College of Gastroenterology, 2017). Chest x-ray: This ordeal is not ordinaryly used due past serviceable imaging for GI issues, but could be accelerationful to administration out other diagnoses such as a hiatal hernia or other abordinary division (Chow, 2015).  Diagnosis:  K27 Peptic Abscess Disease K21.9 Gastro-esophageal diffluence malady succeeding a whileout esophagitis K29.70 Gastritis, unspecified, succeeding a whileout bleeding Source: ICD10Date.com, 2017. Differential Diagnosis:  Diverticulitis Emergent Tenor of Gastroenteritis Esophageal Rupture and Tears in Emergency Medicine Esophagitis Gallstones (Cholelithiasis) Gastroesophageal Diffluence Disease Inflammatory Bowel Disease Viral Hepatitis Acute Cholangitis Acute Coronary Syndrome Acute Gastritis Cholecystitis Cholecystitis and Biliary Colic in Emergency Medicine Chronic Gastritis Source: Epocrates, 2017.  Plan of Care: Initially, this unrepining was established on aggravate the contrary antisecretory tenor such as an histamine-2 receptor competitor or a proton cross-examine inhibitor therapy (PPI) (NIH, 2014). At flourish up, unrepining reported no deliverance in concomitants and ordealed real for H. pylori. He was then treated succeeding a while criterion triple therapy (American Nobility Physician, 2015). At the instant flourish up he recurrent that concomitants fixed during antibiotic triple therapy but returned succeeding finishing the food. He was then placed on salvage therapy succeeding a while moderate another antibiotic, Levofloxacin, a PPI and amoxicillin for 10 days. At flourish up the unrepining was entirely concomitant unhindered. The unrepining was educated respecting feasible succession of PPI therapy to lighten lasting concomitants. He was counseled to shun NSAIDS, alcohol, balmy foods, smoking and to shun mendacious down succeeding eating (American Academy of Nobility Physicians [AAFP], 2015) The unrepining was counseled and educating using the services of a Spanish plainive note-maker and was attached Spanish medication and tenor handouts. He was attached instructions to concede worsening concomitants and when to flourish up in employment.  Medications:  Triple Therapy:  Omeprazole (PPI): 40mg PO QD for 4 weeks Amoxicillin: 1g PO BID for 10 days Clarithromycin 500mg PO BID for 10 days Second Line: Omeprazole (PPI): 40mg PO QD for 10 days Amoxicillin: 1g PO BID for 10 days Levofloxacin 500mg PO QD for 10days References: American Academy of Nobility Physicians (2015). Diagnosis and Tenor of Peptic Abscess Malady and H. pylori Infection. American Nobility Physicians. 91(4):236-242. Retrieved from URL: https://www.aafp.org/afp/2015/0215/p236.htm American College of Gastroenterology (2017) Peptic Abscess Disease. Digestive Health Topic. Retrieved from URL: http://patients.gi.org/topics/peptic-ulcer-disease/ Chow, S. (2015). Peptic Abscess Diagnosis. News Medical Life Sciences. Retrieved from URL: https://www.news-medical.net/health/Peptic-Ulcer-Diagnosis.aspx Epocrates (2017). Peptic Abscess Disease. Retrieved from URL: https://online.epocrates.com/diseases/8035/Peptic-ulcer-disease/Differential-Diagnosis ICD0Data.com (2017). Gastro-esophageal diffluence malady succeeding a whileout esophagitis. Retrieved fromhttp://www.icd10data.com/ICD10CM/Codes/K00-K95/K20-K31/K21-/K21.9 ICD10Data.com (2017). Peptic abscess, seat unspecified. Retrieved fromhttp://www.icd10data.com/ICD10CM/Codes/K00-K95/K20-K31/K27-/K27 ICD10Data.com (2017). Gastritis, unspecified, succeeding a whileout bleeding. Retrieved from URL: http://www.icd10data.com/ICD10CM/Codes/K00-K95/K20-K31/K29-/K29.70 National Institutes of Health [NIH] (2017). Upper GI Endoscopy. Diagnostic Tests. Retrieved from URL: https://www.niddk.nih.gov/health-information/diagnostic-tests