Soap Note Assigment

Enduring referable attributable attributableice to full the soap music. gladden attend attachment 

39-year-old Hardy with epigastric denial
Chief Compliant: “I’ve been having this abdominal denial, and it harmonious attendms approve it won’t go abroad. It inaugurated probably a year since. It used to occur a noncommunicationing times a week, now it hurts complete day.”
Truth of Introduce Illness: Mr. Rodriguez is a 39-year-old hardy that novelly immigrated to the United States from Dominican Republic. He complains of epigastric denial that began approximately individual year since. He describes the denial as “burning” and occurring daily. He states that the denial rarely worsens with eating and rarely it reforms. He states that perfumed foods compel the denial worsen. He admits to weekly NSAID exercitation and drinking 3-4 alcoholic beverages a week. He surrender smoking 6 months since. He drinks an herbal tea except does referable attributable attributable attributable proof any extrication or shift in the signs. He denies any broil, chills, disgust, hematemesis, hematochezia, or melena.
PMH/Medical/Surgical Truth: No truth of gastrointestinal problems in the spent. No truth of surgery. No public garbage allergies.
Medications: Takes ibuprofen “almost daily” coercion aches and denials associated with instituted. Drinks herbal tea meant to reform GI signs.
Significant Race Truth: Enduring states race truth of nature ailment. Father had hypertension and his dame had diabetes. 
Social Truth: Enduring denies smoking. Enduring states that he surrender smoking 6 months since. Enduring states that he drinks 3-4 beers weekly.  No illicit garbages. 
Review of Signs: 
GENERAL:  39-year-old Spanish suggestive enduring. Language referablee-maker introduce. Enduring is brisk and oriented. Afebrile. Enduring denies novel, reserved ponderosity restraintfeiture, broil, chills, imbecility or harass.
HEENT:  Denies dissipation, shift in expectation, nose, or ear problems. Denies afflictive throat.   
SKIN:  No shift in bark, hair or nails. 
CARDIOVASCULAR:  Regular nature blame and rhythm. S1, S2, no murmurs, rubs, or gallops.
RESPIRATORY:  clear to auscultation.
GASTROINTESTINAL:  Soft, downright, non-distended. Normoactive bowel sounds heard in disgusting quadrants. Soft, non-distended, with minimal epigastric delicacy on obscure palpation extinguishedside recoil delicacy or compensating, no hepatosplenomegaly, and no hernia or masses.
GENITOURINARY: Denies problems with urination.  
NEUROLOGICAL:  No dissipation, dizziness, syncope, paralysis, ataxia, callousness or tingling in the extremities. No shift in bowel or bladder guide.
MUSCULOSKELETAL:  Brisk & oriented x3. Denies muscle, tail denial, knee denial or euphuism.
HEMATOLOGIC:  Denies anemia, bleeding or bruising.
LYMPHATICS:  No polished nodes. Denies truth of splenectomy.
PSYCHIATRIC:  Denies truth of debasement or disquiet. Enduring does pointed anxiety encircling paying coercion medications and flourish up visits attributable to noncommunication of insurance. 
ENDOCRINOLOGIC:  Denies exudation, indifferent or ebullition intolerance. Denies polyuria or polydipsia..
Objective Data: 

Temperature: 98.5 Fahrenheit
Nature blame: 78 beats/minute, regular
Respiratory blame: 16 breaths/minute
Blood pressure: 133/82 mmHg
Body Mass Index: 24.8 kg/m2- This BMI is amid typical collocate according to the National Nature, Lung, and Blood Institute (2017). 

Physical Assessment Findings: Enduring is brisk, oriented and is cooperative. 
HEENT:  PERRLA, no nystagmus musicd. Tympanic membranes are pure. External parley canals are typical. Oral pharynx is typical extinguishedside erythema or exudate. Tongue and gums are typical.
Lymph Nodes:  Non-palpable
Carotids: similar bilaterally 2+
Lungs:  clear to auscultation
Heart:  Regular blame and rhythm typical S1 and S2.
Abdomen:  soft, non-tender, non-distended, no masses. 
Genital/Pelvic:  unremarkable
Extremities/Pulses:  typical pulse bilaterally
Neurologic:  A&Ox3, cranial nerves pure
Laboratory and Diagnostic Trialing:
Fecal Occult Blood Trialing: negative
Heliobacter Pylori (H. pylori) serology trial: Actual
CBC with differential to trial coercion other conditions such as anemia or pancreatitis. 
Upper GI endoscopy: can aid to obstruct coercion impairment to the coating of the stomach and to government extinguished malignancies (National Institutes of Health [NIH], 2017)
Upper GI Series: Commonly used in the spent to diagnose peptic abscesss referablewithstanding this trial can misconceive smaller abscesss and does referable attributable attributable attributable allot coercion plain tenor of the abscess (American College of Gastroenterology, 2017).
Chest x-ray: This trial is referable attributable attributable attributable typically used attributable balance powerful imaging coercion GI issues, except could be aidful to government extinguished other diagnoses such as a hiatal hernia or other abtypical analysis (Chow, 2015). 
Diagnosis: 
K27 Peptic Abscess Ailment
K21.9 Gastro-esophageal diffluence ailment extinguishedside esophagitis
K29.70 Gastritis, unspecified, extinguishedside bleeding
Source: ICD10Date.com, 2017.
Differential Diagnosis: 

Diverticulitis
Emergent Tenor of Gastroenteritis
Esophageal Rupture and Tears in Emergency Medicine
Esophagitis
Gallstones (Cholelithiasis)
Gastroesophageal Diffluence Ailment
Inflammatory Bowel Ailment
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 enduring was inaugurated on balance the opposed antisecretory tenor such as an histamine-2 receptor rival or a proton interrogate inhibitor therapy (PPI) (NIH, 2014). At flourish up, enduring reported no extrication in signs and trialed actual coercion H. pylori. He was then treated with model triple therapy (American Race Physician, 2015). At the proximate flourish up he orderly that signs firm during antibiotic triple therapy except returned flourishing finishing the fare. He was then placed on salvage therapy with included another antibiotic, Levofloxacin, a PPI and amoxicillin coercion 10 days. At flourish up the enduring was fullly sign bountiful. The enduring was educated concerning potential sequence of PPI therapy to mitigate abiding signs. He was counseled to escape NSAIDS, alcohol, perfumed foods, smoking and to escape untrue down flourishing eating (American Academy of Race Physicians [AAFP], 2015)
The enduring was counseled and educating using the services of a Spanish suggestive referablee-maker and was consecrated Spanish medication and tenor handouts. He was consecrated instructions to know-again worsening signs and when to flourish up in station. 
Medications: 
Triple Therapy: 
Omeprazole (PPI): 40mg PO QD coercion 4 weeks
Amoxicillin: 1g PO BID coercion 10 days
Clarithromycin 500mg PO BID coercion 10 days
Second Line:
Omeprazole (PPI): 40mg PO QD coercion 10 days
Amoxicillin: 1g PO BID coercion 10 days
Levofloxacin 500mg PO QD coercion 10days
References:
American Academy of Race Physicians (2015). Diagnosis and Tenor of Peptic Abscess Ailment and H. pylori Infection. American Race Physicians. 91(4):236-242. Retrieved from URL: https://www.aafp.org/afp/2015/0215/p236.htm
American College of Gastroenterology (2017) Peptic Abscess Ailment. 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 Ailment. Retrieved from URL: https://online.epocrates.com/diseases/8035/Peptic-ulcer-disease/Differential-Diagnosis
ICD0Data.com (2017). Gastro-esophageal diffluence ailment extinguishedside esophagitis. Retrieved fromhttp://www.icd10data.com/ICD10CM/Codes/K00-K95/K20-K31/K21-/K21.9
ICD10Data.com (2017). Peptic abscess, plight unspecified. Retrieved fromhttp://www.icd10data.com/ICD10CM/Codes/K00-K95/K20-K31/K27-/K27
ICD10Data.com (2017). Gastritis, unspecified, extinguishedside 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 Trials. Retrieved from URL: https://www.niddk.nih.gov/health-information/diagnostic-tests

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