*NURSING > SOAP NOTE > Comprehensive soap note | complete (All)

Comprehensive soap note | complete

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Patient Information Date of encounter: 10/27/2017 1400 Patient: B. G. Age: 33 years Date of Birth: 05/01/1984 Race: Caucasian Sex: Male Insurance: Humana Comprehensive SOAP Laura Gomez Sourc... e of information: Patient is reporter and reliable historian. S – SUBJECTIVE DATA Chief complaint Patient seeking medical attention for “having a lot of heartburn lately”. History of present illness Patient reports history of “occasional heartburn”, but episodes are frequent for past 6 weeks and beginning to interfere with sleep. ● Location: Starts in epigastric region and radiates up to the throat. ● Quality: Burning sensation ● Quantity: Severe discomfort rated 7 out of 10 ● Timing: Episodes occur three times a week in late evening hours, usually after dinner, and lasts one to two hours each ● Setting or context at onset: Increase in work demands. Patient reports having to work a lot of overtime. ● Aggravating factors: worse with consumption of beer or greasy foods and lying flat ● Relieving factors: Semi-reclined positioning and TUMS and “getting in shape” ● Associated manifestations: Abdominal “fullness”, belching and occasional small regurgitation of stomach contents ● Self-treatment: Extra strength TUMS and sleeping with extra pillows or in his recliner ● Significant past medical history: Patient reports history of heartburn. Patient also reports history of obesity and currently being “overweight again”. Patient verifies family history of obesity as well. Past medical history ● Childhood illnesses: Chickenpox as a toddler ● Adult illnesses: Obesity beginning in college, but patient reports reaching healthy weight with diet and exercise in 2008. ● Immunizations: Up to date. Last influenza in October 2017 and last Tdap in July 2016. ● Health maintenance: Yearly physicals for work, annual eye exams and regular dental cleanings ● Injuries/Accidents: Patient reports meniscus tear playing basketball in 2009 and head laceration from altercation in 2013. ● Hospitalizations/Surgeries: Surgery to repair meniscus tear with normal postoperative hospitalization [Show More]

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