Gastroesophageal Reflux Disease (GERD): SOAP Note

Gastroesophageal Reflux Disease (GERD): A Comprehensive SOAP Note for a 34-Year-Old Obese Male

 

This is a comprehensive SOAP note for an obese 34-year-old male who comes in with GERD symptoms.

Primary diagnosis: Gastroesophageal reflux

Differential diagnosis: Angina, Gastritis, Peptic ulcer

References no older than 3 years.

No cover page.

 

Solution

 

THE HISTORY AND PHYSICAL (H&P)

Patient’s Details

Initials: P.S.                Age: 34 years                     Race: African-American                    Gender: Male

1. Chief Complaint

“I have a burning sensation on my chest usually after eating. Sometimes I feel like swallowed food is moving up my chest towards the mouth. These symptoms worsen at night when I am lying down.”

1. History of Present Illness (HPI)

A 34-year-old African-American male has come to the clinic unaccompanied. The patient’s chief complaint is a burning sensation on his chest which usually occurs after eating and are worsened at night when he is in a lying position. The patient sometimes feels as if swallowed food is moving up his chest towards the mouth, a condition known as regurgitation. Other associated symptoms include a bitter taste in the mouth, shortness of breath, and chest pain. As reported by P.S., his symptoms have lasted for more than 4 weeks.

Although the symptoms do not occur every day, the patient indicates that they can happen either once or twice a week. Eating late at night and consuming fatty or fried foods trigger the symptoms while they rarely happen when he eats dinner early. P.S. is not taking any medications to improve his current symptoms. However, he is currently on Orlistat 120 mg which he is taking orally three times daily to manage obesity that he has been having for the past one year.

III. Past medical history (PHx)

1. Childhood illnesses

• Cold and flu.
• Malaria
• Pneumonia

1. Immunizations

P.S. received the following vaccines according to schedule;

• hepatitis B vaccine
• polio vaccine
• rotavirus vaccine
• varicella vaccine
• measles, mumps, rubella (MMR) vaccine
• hepatitis A vaccine
• pneumonia vaccine
• diphtheria, pertussis, and tetanus (DPT) vaccine.

His last tetanus booster was given at the age of 26 years. His last influenza vaccine was a year ago. The patient indicates that he has not been vaccinated against COVID-19.

1. Adult Illnesses

Denies a history of adulthood hospitalizations. He was diagnosed with obesity in February 2021.

1. Operations

Denies surgical history

1. Allergies

No known drug or food allergies reported.

1. Medications

Orlistat 120 mg taken orally three times a day

1. Complimentary treatments

P.S. denies using any complimentary treatments to manage his current symptoms

1. Family history

Father has been having stroke for the past five years. Mother has no medical condition. Paternal grandparents are deceased while maternal grandparents are alive. The patient’s paternal uncle has obesity. P.S. is the first born in a family of five children. His four siblings are all alive.

1. Social history

P.S. is a university graduate. He is a veterinary doctor and is employed in a livestock company. He is married to one wife and they are blessed with 2 kids, a boy and a girl. P.S. stays with his family in a rental family in town. He occasionally consumes alcohol whenever he goes out to party with friends. He denies cigarette smoking. He also denies using illicit drugs such as marijuana, cocaine, or heroin. P.S. is on a restricted diet as advised by the physician after he was diagnosed with obesity.

His diet mostly comprises of fatty foods because Orlistat should be taken with foods that contain fats. He engages in exercise daily by going to a gym. He also plays soccer with his friends over the weekends. However, the patient states that he started to engage in exercise just a year ago when he was diagnosed with obesity.

1. Review of Systems

General: Reports that his weight has been reducing gradually since he started to use obesity medications. Denies nausea, vomiting, or fever. Reports regurgitation, heartburn, chest pain, and shortness of breath.

Skin: Denies hair loss or thinning. No bruises, pruritus, redness, or rashes on the skin reported. Does not report brittle nails or nail breakage.

HEENT:

Head: Denies physical head injury. Denies a headache. No nasal stuffiness reported. Does not report nasal discharge or obstruction. No

Eyes: Does not report redness and pain in the eyes. Reports blurred vision. Does not report a history of cataracts. Denies using contact glasses. Does not report double vision or excessive tearing.

Ears: Denies ear pain, hearing loss, ear infection, or hearing in the ears.

Nose and sinuses: Denies recent changes in smell. Denies a history of nasal infections.

Mouth and throat: Does not report mouth sores, ulcers, pain in the mouth, or mouth dryness. Does not report hoarseness of the throat. Has good dentition, denies pain in the gums. Does not report a history of mouth or throat infections.

Neck: Denies swollen lymph nodes. Denies pain in the neck region. Does not report goiter or abnormal lumps in the neck.

Lymphatics: Denies swollen lymph nodes or axillae.

Breasts: Does not report nipple pain or discharge. Denies lumps or masses on the breasts.

Pulmonary: Denies breathing difficulties. Denies a cough. No hemoptysis reported. Denies pleuritic chest pain, wheezing, or cyanosis. Denies a history of recurrent pneumonia or tuberculosis.

Cardiovascular: Reports chest pain and shortness of breath. Denies irregular heartbeat, or heart murmurs. Does not report a history of high blood pressure. Denies a history of cardiovascular disease such as ischemic attack.

Gastrointestinal: Reports obesity. Reports heartburn that occurs after eating. Reports regurgitation that worsens at night, especially when he is in a lying position. Reports a bitter taste in the mouth. Reports regurgitation that has lasted for more than 4 weeks and happens either once or twice a week. Eating late at night and consuming fatty or fried foods trigger the symptoms while they rarely happen when he eats dinner early. Report dysphagia. Denies abdominal pain or diarrhea. Denies constipation. Denies nausea or nausea. Denies changes in bowel movements. Reports excessive belching. Denies a history of gallbladder problems.

Urinary: Reports nocturia or increased urine volume and frequency at night. Denies hematuria or dysuria. Denies a reduction in urine volume. Denies a history of kidney stones, urinary tract infections, or urinary incontinence.

Genital tract (male): Denies a history of a sexually-transmitted disease (STD). Denies pain in the genitalia. Denies swelling in the testicles. No penile discharge or hernias reported.

Musculoskeletal: Does not report pain in the joints. Denies joint stiffness or pains. No joint swelling, joint tenderness, backache, or limitations of motion. Denies a history of arthritis or fractures.

Neurologic: Denies seizures, tingling, tremors, or numbness of limbs. Denies headaches muscle atrophy, dizziness, or memory changes.

Psychiatric: Denies sleep disturbance, depression, or anxiety. Does not report nervousness, insomnia, or suicidal ideation.

Endocrine: No heat or cold intolerance. Denies excessive thirst, abnormal sweating, or excessive hunger reported. No thyroid trouble or excessive urination.

Hematologic: No anemia, easy bruising, or uncontrolled bleeding. Denies a history of blood-related disorders such as sickle-cell disease.

VII. Physical examination

Vital signs: BMI: 32.1. Blood pressure: 128/78, temperature; 37.1 degree Celsius, pulse; 92 beats per minute, respiratory rate; 19 breaths per minute, weight; 200 pounds.

General appearance: P.S. is well-groomed and neatly dressed. He is oriented to time, place, and person. He looks healthy and strong.

Skin: Skin is without rashes, sores or lesions. It is warm, intact, and dry. No cyanosis observed on the nail beds.

HEENT:

Head: The head is normocephalic and without trauma. It lacks evidence of palpable masses, scarring, or depressions. Hair is evenly distributed on the scalp and of normal texture.
Eyes: No signs of drainage or discharge. Eyelids are without swelling or lesions. Cornea is not opacified. Conjunctivae are clear without exudates or hemorrhage. Non-icteric sclerae. Visual acuity is 20/20.

Ears: The external ear and ear canal are non-tender without edema. The ear canal is clear without discharge. No signs of ear blockage. The tympanic membrane is pale grey in color in both ears.
Nose: Nasal turbinates not enlarged. Nasal mucosa is pink, hairy, and moist. No evidence of nasal tenderness. Midline-positioned septum.

Throat: Oral mucosa is without sores, lesions, or ulcers. It is pink and moist with good dentition. Throat is non-erythematous. The pharynx is pink in appearance. No evidence of tonsillar exudates, edema, or pharyngeal injection.

Neck: Midline-positioned trachea. Absence of unusual masses or pulsations. No jugular venous distention. Thyroid is palpable.

Nodes: No swelling of the inguinal, axillary, or epitrochlear nodes.

Breasts: No tenderness, discharge, or masses.

Chest: No deformities on inspection. Normal breath sounds, wheezes, crackles, rubs, or rhonchi on auscultation. No fremitus detected on palpation.

Heart: Visible PMI on inspection. Normal heart rate, S1, S2, without galloping, murmurs, or rubbing. Normal heart rhythm, no heaves, lifts, or excitement. No evidence of edema on the periphery. Varied bilateral peripheral pulses, capillary refill less than 3 seconds.

Abdomen: Bowel sounds heard in all quadrants. No scars. Abdominal tenderness present. Bloating and abdominal distention observed.

Back/spine: No mobility challenges. No evidence of deformities on the neck and back. No curvature. No CVA tenderness.

Extremities, including exam of pulses: No tremor, deformities, or swellings in upper and lower extremities. No evidence of joint tenderness or effusion.

Genitalia/Rectal (male): No lesions on genitalia, pubic hair evenly distributed. No evidence of penile inflammation or discharge.

Neurologic:

Mental status: P.S. is attentive and able to concentrate. He has a normal speech. No evidence of memory impairment.

Cranial nerves: Crania nerves II-IX have full EOM’s. They are intact with evidence of visual fields.

Motor: Muscle rigidity absent. Normal gait and good balance. Muscle strength on all joints is 5/5.

Sensory: Reflexes are 2+. Light touch and pricking has revealed sensitivity in lower and upper limbs.

VIII. Problem list

• Heartburn after eating that worsens at night
• Regurgitation
• Presence of balls of food in the esophagus
• Bitter taste in the mouth
• Chest pain
• Dysphagia
• Shortness of breath

1. ASSESSMENT (Which is your Diagnosis)

• Gastroesophageal reflux disease (GERD)

1. Differential Diagnosis

• Angina
• Gastritis
• Peptic Ulcers

X1. Plan:

1. Diagnostic (labs etc.)

• Upper endoscopy
• Esophageal manometry
• Ambulatory acid (pH) probe test
• X-ray of the upper digestive system

1. Medications

-Replace Orlistat with Bupropion-naltrexone to limit fat intake

-Antacids such as Tums and Mylanta: Act by neutralizing the excess acid

– H-2-receptor blockers such as famotidine: Act by reducing acid production

-Proton pump inhibitors such as esomeprazole: Acts by healing the irritated esophagus

-Baclofen: Act by strengthening the lower esophageal sphincter

1. Referral

-Gastroenterologist for further gastrointestinal tract (GIT) evaluation

1. Follow-Up: 2 weeks
2. Patient education

Your primary diagnosis is gastroesophageal reflux disease (GERD). GERD is a chronic condition in which contents of the stomach move upwards into the esophagus and the throat. The acid in the food content cause irritation of the wall of the esophagus. Symptoms of GERD include heartburn after eating that may worsen at night, regurgitation of movement of swallowed food from the stomach upward to the esophagus, feeling a lump of food in the throat, and a bitter taste in the mouth due to the presence of stomach acid.

Some patients also present with chest pain and shortness of breath. Obesity, speedy eating, eating fatty and fried foods, eating late at night, and a familial history of GERD increase a person’s risk of developing the condition. The pathophysiology of GERD entails a functional abnormality of the esophageal sphincter which prevents it from closing properly after food gets into the stomach.

A breakdown in the defense mechanism of the esophagus can also lead to physiological abnormalities that present as GERD. This diagnosis is well supported by your symptoms and some of the named risk factors. You will be given medications that you will be required to take as prescribed.  First, Orlistat will be replaced with Bupropion-naltrexone to limit fat intake. You will also be given Tum, an antacid to neutralize the excess acid; Famotidine, a H-2-receptor blocker to reduce acid production; Esomeprazole, proton pump inhibitor to heal the irritated esophagus; and Baclofen to strengthening the lower esophageal sphincter.

The non-pharmacological approaches that you will be required to follow include; avoid fatty and fried foods, avoid eating late in the night, stick to your restricted diet and continue engaging in exercise for weight management, avoid consuming large meals at once, and always rest your head on a pillow raised to about 6 inches from the bed surface. Following these recommendations will prevent you from suffering health complications associated with GERD such as narrowing of the esophagus, developing open sores in the esophagus, and Barrett’s esophagus.

You will be referred to a gastroenterologist for further gastrointestinal tract (GIT) evaluation. Do not hesitate to call or visit the clinic in case you develop problematic symptoms during medication use. You are also advised to visit the clinic after 2 weeks for evaluation and further guidance.

References

 

Chen, S., Du, F., Zhong, C., Liu, C., Wang, X., Chen, Y., Wang, G., Gao, X., Zhang, L., Li, L., & Wu, W. (2021). Gastroesophageal reflux disease: recent innovations in endoscopic assessment and treatment. Gastroenterology Report, 9(5), 383–391. https://doi.org/10.1093/gastro/goab029

Katz, P. O., Dunbar, K. B., Schnoll-Sussman, F. H., Greer, K. B., Yadlapati, R., & Spechler, S. J. (2022). ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. The American Journal of Gastroenterology, 117(1), 27-56. doi: 10.14309/ajg.0000000000001538.

Katzka, D. A., & Kahrilas, P. J. (2020). Advances in the diagnosis and management of gastroesophageal reflux disease. British Medical Journal, 371, m3786. doi: 10.1136/bmj.m3786. PMID: 33229333.

Kröner, P. T., Cortés, P., & Lukens, F. J. (2021). The medical management of gastroesophageal reflux disease: A narrative review. Journal of Primary Care & Community Health, 12, 21501327211046736. https://doi.org/10.1177/21501327211046736

Naik, R. D., Evers, L., & Vaezi, M. F. (2019). Advances in the diagnosis and treatment of GERD: new tricks for an old disease. Current Treatment Options in Gastroenterology, 17(1), 1-17. doi: 10.1007/s11938-019-00213-w.

Săraru, E. R., Enciu, V., Peagu, R., & Fierbinţeanu-Braticevici, C. (2021). Advances in the diagnosis of GERD. Romanian Journal of Internal Medicine, 59(1):3-9. doi: 10.2478/rjim-2020-0027. PMID: 33010143.