SOAP NOTE: PEPTIC ULCER DISEASE DUE TO HELICOBACTER PYLORI

SAMPLE FOCUS NOTE

CHIEF COMPLAINT (C/C)

“I have trouble breathing”

HISTORY OF PRESENT ILLNESS (HPI)
24-year-old single,domicile, Hispanic female presents to the Clinic with complain of difficulty breathing times 3 days. She reported her symptoms began with her having what she considered a common cold 3days,ago andworsened over the next 2 daysresulting in persistent cough, wheezing, chest tightness, increased dyspnea, and severe anxiety. Patient report that walking up the stairs to her bedroomor doing any type of activity worsen her SOB and chest tightness.

She denies any fever or chills, she denies chest pain but report wheezing accompanied by chest tightness and dyspnea. She denies headache nasal or sinus congestion. She reports drinkinghot tea andusing an old albuterol pump she had at home with little or no relief. Patient report history of childhood asthma but has not experienced an attack or symptoms in the last sixyears and reports never having experienced this level of severity of symptoms. She denies any know triggers, denies having any pets at home or exposure to cat dander, dust mites or grass or tree pollens.

PAST HISTORY
CHILDHOOD ILLNESSES:

Denies chickenpox measles, mumps, rubella, whooping cough, rheumatic fever, scarlet fever, or polio.
IMMUNIZATION:
Childhood vaccine

Immunization
– Hepatitis B: 3/3
– Diphtheria, Tetanus, and Pertussis: 5/5
– Booster dose of TDAP 2018

– Hemophilus influenza type B: 4/4
– Pneumococcal conjugate: 4/4
– Inactivated Polio- virus- 4/4
– Measles, Mumps, Rubella: 2/2

HPV Three dose Series completed 2008
Influenza 10/21

COVID vaccine Completed 1/14/21, 2/7//21 and booster dose 9/18/21

ADULT ILLNESS:

Asthma
PSYCHIATRIC ILLNESS:

Denies past or present psychiatric illnesses.
ACCIDENTS or INJURIES:

Denies accidents or injuries
OPERATIONS: Denies
ALLERGIES: No known drug or food allergies.
MEDICATIONS:

Albuterol Ventolin HFA 2 puffs Q 4-6 hours PRN
COMPLIMENTARY TREATMENTS: None
FAMILY HISTORY:
Maternal grandmother: Unknown deceased
Maternal grandfather: Unknown deceased
Paternal grandmother: Unknown deceased
Paternal grandfather: Unknown deceased
Mother Age 50 HTN
Father  Age 52 Asthma
3 siblings/ sisters 21, 16, 8: No Known Medical problems

SOCIAL HISTORY
Education: High school diploma
Occupation: office administrator
Living situation: Lives with parents in private home
Financial: Employed and lives with her parents
Tobacco: None
Alcohol: Socially drinks wine one glass per month
Drugs: Smoke Marijuana occasionally 1 blunt every 3-4 months

Sexual history: Heterosexual, sexually active, one partner
Marital status: Single
Exercises: No formal exercise routine

REVIEW OF SYMTEMS

GENERAL: Well-nourished female, with normal height and weight, who denies fever, chills, body aches, fatigue, night sweats or any changes in sleeping pattern.

HEAD: Denies headache or head injury

EYES:

Denies wearing glasses or contact lens; last vision check,10 months ago; denies pain redness, excessive tearing, double vision, floaters, lost of visual field cataract or glaucoma.

EARS: Denies hearing loss, ringing in the ear’s, earaches, or ear infections.

NOSE AND SINUS: Report having running nose and nasal stuffiness three days ago.  Denies hay fever, nose bleeds, sinus congestion, obstruction, change in the ability to smell. Sneezing postnasal drip or history of polyps.

MOUTH AND THROAT:

Denies, soreness, dryness. Pain ulcers, sore tongue, bleeding gums, pyorrhea, dental carries, sore throat, hoarseness, history of strep throat or recurrent sore throat or rheumatic fever.

RESPIRATORY: Reports nonproductive cough, dyspnea, wheezing, shortness of breath and chest tightness times three days. Used albuterol with no relief. Reports history of childhood asthma with last asthma attack 6 years ago. Denies hemoptysis, bronchitis, emphysema, pneumonia, tuberculosis, or pleurisy. Denies TB or exposure to TB.  Last PPD done 10 months ago and was negative. No history of pneumonia or history of environmental exposure
CARDIAC: Denies chest pain, or palpitations, denies paroxysmal nocturnal dyspnea, denies orthopnea, edema, palpitations, hypertension, known heart disease, rheumatic fever, heart murmurs, rheumatic fever syncope or near syncope, pain in posterior calves.

GASTROINTESTINAL: Denies abdominal pain, trouble swallowing, heartburn, problem with appetite, nausea, vomiting, regurgitation, vomiting of blood, indigestion, food intolerance, excessive belching, burping, or passing of gas; denies constipation, diarrhea, jaundice, liver or gallbladder trouble, hepatitis. Bowel movement 1-2 times daily, soft brown stool.

PHYSICAL EXAMINATION

VITAL SIGNS: T 98.6 ºF, P68, RR 24, BP 126/70 (right arm, sitting, automatic), 126/68 (right arm, standing, automatic), oxygen saturation 94 % room air, height 5 ft. 6 in., weight 168 lbs. BMI 27.1.
GENERAL SURVEY: Alert and oriented x 3. Appears, fatigued, and anxious.  She is slightly overweight, well-nourished, well-groomed and appears stated age of 24.

HEAD:  Normocephalic, atraumatic, scalp clean, no dandruff, hair short, black, evenly distributed.

EYES:Symmetrical, lids without drooping or ptosis, sclera white, no icterus or muddy appearance, conjunctiva pale, corneal clear, PERRLA, EOM intact, light reflex direct and consensual brisk and intact. Visual acuity 20/20 bilateral.  Optic disc with intact red reflex,optic discwith sharp margin, small central cup, and no edema. Retinal vessels intact, no A/V nicking or cotton wool spots.

EARS: Symmetrical and in line with the outer canthus of the eyes, manipulation of the pinna without tenderness. Ear canals clear, no cerumen observed, tympanic membrane pearly grey with good cone of light bilaterally. Acuity good to whispered voice. Rinne test AC>BC. Weber -midline

NOSE:

Nares congested, with small amount of clear discharge; nasalseptum intact, turbinates’ slightly enlarged and boggy, Frontal and maxillary sinus non tender to palpation and percussion.

THROAT:

LIPS: dry, scaly, tongue midline, moist and without fasciculation; teeth in good repairs, no cavities; gum pink, no gingivitis, oral mucosa pink and moist, no halitosis. Tonsils without erythema and non-edematous, no injection or exudates; uvula midline and moves up and down with pronation.

NECK: Supple, FROM, Thyroid isthmus palpable, smooth, no nodules, mass, or tenderness.  Trachea midline, no stridor, carotid upstroke brisk, no bruit.  No JVD.RESPIRATORY: Chest Anterior/Posterior thorax symmetrical, normal diaphragmatic excursion: Tactile fremitus diminished, in all lung fields; No tenderness on palpation of anterior and posterior chest. Percussion notes hyperresonance;Lungs with scattered wheezing in all lung fields no rales, rhonchi, or rubs.

CARDIOVASCULAR: No increase carotid pulsation on inspection No visible PMI; No palpable lifts, heaves, or thrill.  PMI palpated at the 5 ICS, MCL; No carotid bruit auscultated; Bilateral carotid upstrokes brisk without bruits. No increase jugular venous pulsations; JVP-6 CM H2O. Heart sound one (S1) and heart sound two (S2) – normal; No S3 or S4; No murmurs, rubs, heaves, or gallops.

Abdomen: Protuberant, no scars. Bowel sounds active in all four quadrants; No abdominal guarding, or tenderness; Percussion notes tympanic in all four quadrants. No shifting dullness Liver span 5-6 cm dullness. No tenderness on light and deep palpation Liver, spleen, and kidneys non-palpable.

PROBLEM LIST

SOB
Chest tightness
Dyspnea
Wheezing

ASSESSMENT

Asthma Exacerbation

Differential Diagnosis
URI
Mild persistent asthma
Rhinitis
Sinusitis
Viral syndrome
COPD

DIAGNOSTIC PLAN:

Diagnostic

Pregnancy test

BMP, CBC

1) PFT
(2) Chest x-ray

Medication

Nebulized treatment albuterol 0.083% 1 dose via nebulizer stat

(1)   Albuterol Ventolin HFA 2 puffs Q 6 hours PRN

(2)    Medrol/ methylprednisolone dose pack as prescribe

REFERRAL:
Pulmonologist

Follow UP in 2 weeks:

PATIENT EDUCATION
You are being diagnosed with asthma exacerbation. Asthma is a chronic inflammatory disorder of the airways characterized by increased responsiveness of the tracheobronchial tree to various stimuli resulting in reversible narrowing and inflammation of the airways.  Symptoms you make experience includes wheezing associated with cough, and sputum production, shortness of breath, chest tightness breathlessness and anxiety.

Your asthma may be precipitated by cat allergen/dander, house dust mites ‘cockroaches as well as trees and pollen. Viral illness, such as in your case, can also induce airway obstruction.  You will continue to take your albuterol inhaler; this is your rescue medication. You will also start using another asthma medication which is a corticosteroid named Medrol, methylprednisolone dose pack. On day one, you will take 24 mg in four divided dose, every six hours. On day two, you will take 20 mg at the same time schedule of day one.

On day three, 16 mg, On day four, 12 mg, On day five 8 mg and on the last day 4 mg.  I am referring you to a pulmonologist to follow up for a chest x-ray and spirometry testing to assess your lung functioning and vital capacity. Continue to exercise as tolerated. Hand washing is important to prevent exposure to additional cold/viruses. Continue your physical activity as much as you can tolerate.If you experience worsening or lingering symptoms, do contact the medical office, or call 911 immediately.

SOAP NOTE: PEPTIC ULCER DISEASE DUE TO HELICOBACTER PYLORI

CHIEF COMPLAINT (C/C)

“I have epigastric pain, heartburn, bloating, and excessive release of gas. The epigastric pain and heartburn are severe when I am hungry and they go away when I eat some food.”

HISTORY OF PRESENT ILLNESS (HPI)

A 38-year-old Latino male patient has visited the clinic unaccompanied. His chief complaint is epigastric pain that occurs together with heartburn, bloating, and excessive release of gas. These symptoms started a year ago. Initially, the used to occur when the patient is hungry but their frequency have increased to about twice a day. According to the patient, the epigastric pain and heartburn are worsened with hunger but they resolve when he eats some food.

They are also triggered when he consumes, fruits, spicy foods, and some beverages such as fresh juice. The patient reports that he had a sprain of the ankle joint about a year ago and that he often uses non-steroidal anti-inflammatory drugs (NSAIDs) to relieve the pain which has never gone away completely. He denies using any other medications apart from NSAIDs.

PAST HISTORY

CHILDHOOD ILLNESSES:

Denies a history of measles, mumps, rubella, whooping cough, rheumatic fever, scarlet fever, or polio.
IMMUNIZATION:
Childhood vaccine Immunization
– Hepatitis B: 3/3
– Diphtheria, Tetanus, and Pertussis: 5/5
– Booster dose of TDAP 2018

– Hemophilus influenza type B: 4/4
– Pneumococcal conjugate: 4/4
– Inactivated Polio- virus- 4/4
– Measles, Mumps, Rubella: 2/2

-Influenza 01/22

COVID vaccine Completed 10/17/21, 02 /20/22.
ADULT ILLNESS: The patient had malaria last year. He was successfully treated at home without hospitalization because his symptoms did not require hospital admission. He also suffered a sprain on the ankle joint about 12 months ago. He was treated as an outpatient without hospitalization.
PSYCHIATRIC ILLNESS: Reports a history of alcohol use disorder, depression, and anxiety.
ACCIDENTS or INJURIES: Suffered a sprain on the ankle joint about 12 months ago when he was playing soccer.
OPERATIONS: Denies a history of surgery

ALLERGIES: No known drug or food allergies.
MEDICATIONS: Reports NSAIDs use.

COMPLIMENTARY TREATMENTS: None
FAMILY HISTORY: Father is alive and he is currently 70 years old. He is healthy without a serious medical diagnosis. Mother is 66 years old and has not been diagnosed with a serious health condition. The patient is the first born in a family of 2 children. His younger sister is healthy. The patient does not have any information regarding the cause of death of his maternal grandparents. His paternal grandmother has hypertension while his paternal grandfather is healthy.

SOCIAL HISTORY
Education: A diploma graduate
Occupation: Surveyor
Living situation: Lives with his family in a rental house
Denies a history of childhood asthma. Denies a history of hemoptysis, bronchitis, emphysema, pneumonia, tuberculosis, or pleurisy. Does not report TB or exposure to TB. Last physical check-up for pulmonary function was two years ago. Denies a history of pneumonia or a history of exposure to chemicals.

Physical activity: The patient engages in physical activity over the weekends by playing soccer. He decided to reduce the frequency of playing soccer since he suffering an ankle sprain.
CARDIAC: Denies chest pain, or palpitations. Denies paroxysmal nocturnal dyspnea. Does not report orthopnea, edema, palpitations, hypertension, or known heart disease. Denies rheumatic fever, heart murmurs, or pain in posterior calves.

GASTROINTESTINAL: Reports epigastric pain heartburn, bloating, and excessive release of gas. The epigastric pain and heartburn are severe when the patient is hungry and they go away when he eats some food. Consumption of fruits, spicy foods, and some beverages such as fresh juice triggers the epigastric pain and heartburn. Reports dyspepsia or indigestion. Reports getting full quickly whenever he consumes food.

PHYSICAL EXAMINATION

VITAL SIGNS: BP: 128/85 (sitting, automatic), P: 89, RR: 18, T: 36.5 Ht: 62 inches Wt: 172 lbs; BMI: 22.8.
GENERAL SURVEY: Alert and oriented to time, person, and place. No evidence of acute distress or fatigue. Well nourished. The patient’s appearance is appropriate for the stated age. Reports indigestion and nausea.
SKIN: Skin is smooth, warm, dry, and intact without rashes, or lesions. Nail beds are pink with no evidence of clubbing or cyanosis.
HEAD:  The head is normocephalic and atraumatic. Hair is short. There is no evidence of hair loss or alopecia. There is no evidence of hair thinning or broken hair shafts. Hair is evenly distributed throughout the scalp. Hair texture is normal.

EYES: Clear conjunctivae on both eyes. Both eyes are symmetrical. Lids are without drooping or ptosis. Both sclerae are white. No evidence of hemorrhage or exudates. No icterus or muddy appearance on the sclerae, conjunctivae are pale, corneal clear, PERRLA, EOM are intact, light reflex direct and consensual brisk and intact. No swellings of lesion on eye lids. Visual acuity 20/20 bilateral.  Optic disc with intact red reflex, optic disc with sharp margin, small central cup, and no edema. Retinal vessels intact, no A/V nicking or cotton wool spots.

EARS: Internal and external ears are without edema or tenderness. Both ears are symmetrical and are in line with the outer canthus of the eyes. The pinna can easily be manipulated without difficulties. Rinne test AC>BC. No evidence of obstruction of the ear canals. No evidence of cerumen observed. The tympanic membrane IS pearly grey with good cone of light bilaterally. Weber -midline. Acuity good to whispered voice.

NOSE: Nasal mucosa is moist and pink. No evidence of discharge or nasal congestion. Turbinates are neither boggy nor enlarged. The sinuses are non-tender. The nasal septum is intact and positioned midline.

MOUTH AND THROAT: The buccal mucosa is moist. The tongue is positioned midline, moist, pink, and without fasciculation. The teeth in good arrangements on the gums. No evidence of cavities. The gum is pink with no evidence of gingivitis or halitosis. No tonsils or erythema observed on the throat. No exudates, lesions, or nodules. The pharynx is pink in appearance.
NECK: The trachea is positioned midline. The neck is supple with no adenopathy observed. Thyroid gland is normal without masses. Palpable thyroid isthmus. Carotid pulse 2+ bilaterally without bruit. No jugular vein distention (JVD). No stridor observed.
RESPIRATORY: Normal diaphragmatic excursion. The chest wall is symmetric and without deformity. No tenderness on palpation of anterior and posterior chest. No signs of trauma observed. No evidence of respiratory distress. Clear lung sounds in all lobes of the lungs bilaterally without wheezes, rales, or Ronchi. Normal Resonance on percussion of all lung fields.
CARDIOVASCULAR: The external chest is normal in appearance without palpable lifts, heaves, or thrills. Invisible PMI and is palpated in the 5th intercostal space at the midclavicular line. Normal heart rate and rhythm. No murmurs, rubs, or gallops. S1 and S2 are heard and are of normal intensity. No increase carotid pulsation on inspection; No carotid bruit auscultated; Bilateral carotid upstrokes brisk without bruits. No increase jugular venous pulsations; Heart sound one (S1) and heart sound two (S2)-normal; No S3 or S4; No murmurs, rubs, heaves, or gallops.

ABDOMEN: Abdomen is soft and protuberant, no scars. Normal bowel sounds active in all four quadrants; No abdominal guarding, or tenderness; Percussion notes tympanic in all four quadrants. No shifting dullness. No tenderness on light and deep palpation. Liver, spleen, and kidneys non-palpable. Umbilicus is midline with no evidence of herniation. No abnormal masses observed.

PROBLEM LIST
Epigastric pain

Heart burn

Symptoms being triggered by hunger and consumption of fruits, spicy foods, and some beverages

Symptoms resolve with eating

Epigastric pain and heart burn started about a year ago

Bloating

Indigestion/dyspepsia

Excessive release of gas

Getting full quickly

Use of NSAIDs

ASSESSMENT
Peptic ulcer disease due to Helicobacter pylori

DIFFERENTIAL DIAGNOSIS
Gastroesophageal reflux disease (GERD)

Irritable Bowel Syndrome (IBS)

Cholecystitis

Pancreatitis

DIAGNOSTIC PLAN:

Diagnostics

-Stool monoclonal antigen test

-Urea breath test

-Rapid urease test

-Bacterial culture

-Endoscopy with biopsy

MEDICATION

-Proton pump inhibitors

-1 g of amoxicillin taken twice a day

-500 mg of clarithromycin taken twice a day

REFERRAL:
-No referrals are required at this time

Follow UP in 2 weeks

PATIENT EDUCATION

Your primary diagnosis is peptic ulcer disease caused by a microorganism called Helicobacter pylori. H. pylori is a type of bacteria that is usually found in the stomach. Certain triggers such as continued use of NSAIDs usually affect its normal concentration in the stomach leading to problematic symptoms that manifest as disease. Patients with peptic ulcers due to H. pylori usually present with epigastric pain or severe pain in the upper parts of the abdomen, heartburn, bloating, and excessive release of gas (American College of Gastroenterology, 2022; Hudnall et al., 2022).

The abdominal pain is mostly triggered by hunger, fruits, and beverages with high acid content. Eating some food relieves the epigastric pain and heartburn. Other common symptoms are indigestion, nausea, and vomiting (Narayanan et al., 2020). Your peptic ulcer may be attributed to continued use of NSAIDs which might have triggered the excessive production of H. pylori in the stomach (Kowada & Asaka, 2022).

You will be treated with proton pump inhibitors, 1 g of amoxicillin taken twice a day, and 500 mg of clarithromycin taken twice a day (American Academy of Family Physicians, 2020). You are advised to adhere to the recommended regimen and call the clinic in case you experience problematic symptoms. You are advised to engage in physical activity and consume a diet that is rich in proteins and vegetables. You should limit the consumption of fruits, spicy foods, and beverages with high acid content (Mayo Clinic, 2022). Feel free to reach the clinic using the number provided in your forms if you experiencing problematic symptoms.

References

American Academy of Family Physicians. (2020). Diagnosis and treatment of peptic ulcer disease and H. pylori infection. https://www.aafp.org/afp/2015/0215/p236.html

American College of Gastroenterology. (2022). Peptic ulcer disease. https://gi.org/topics/peptic-ulcer-disease/

Hudnall, A., Bardes, J. M., Coleman, K., Stout, C., Regier, D., Balise, S., Borgstrom, D., & Grabo, D. (2022). The surgical management of complicated peptic ulcer disease: An EAST video presentation. The Journal of Trauma and Acute Care Surgery, doi: 10.1097/TA.0000000000003636.

Kowada, A., & Asaka, M. (2022). Economic and health impacts of Helicobacter pylori eradication strategy for the treatment of peptic ulcer disease: A cost-effectiveness analysis. Helicobacter, 27, e12886. doi: 10.1111/hel.12886.

Narayanan, M., Reddy, K. M., & Marsicano, E. (2020). Peptic ulcer disease and Helicobacter pylori infection. Missouri Medicine, 115(3), 219–224.

Mayo Clinic. (2022). Helicobacter pylori infection. https://www.mayoclinic.org/diseases-conditions/h-pylori/diagnosis-treatment/drc-20356177