NURS 623 SOAP note practicum adult 2 GERD.

NURS 623 SOAP note practicum adult 2 GERD.Chief Complaint Patient complains of hoarse voice and frequent upset stomach “heartburn” episodes History of Present Illness 78-year old female with complaint of hoarse voice and frequent episodes of an upset stomach and” heartburn” that started roughly 1 month ago. She reports episodes occur at least 3-4 times a week or more. She reports that the she thought the problem was caused after eating spicy foods, but it continued after changing her diet and even with non-spicy meals. She reports that she has been taking tums when the episodes occur but, she came in now due to a hoarse voice and phlegm production. Past Medical History Past Medical history: Hypertension, depression, type 2 diabetes and hypothyroidism Past surgical history: None Patient is current in immunizations Allergies: Penicillin Current medications include: Tums extra strength 2 tabs TID with meals PRN, metformin ER 1000mg PO QPM, levothyroxine 75 mcg po q day, Amlodipine 10 mg po q day. Losartan 50 mg po q day. Bupropion XL 150 ER po q day. Paxil: 40 mg po q day. Family History Include parents, siblings; grandparents if applicable/known, cause of death, age, pertinent medical illnesses Mother: Type 2 diabetes and hypertension Father: Asthma, and Hypertension Brother: hypertension, type 2 diabetes Sister: Type 2 diabetes Personal/Social History Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if known Patient is a retired schoolteacher. She is a heterosexual widowed female. Pt denies any illicit drug use and uses alcohol occasionally. She does not smoke or use chewing tobacco. Pt does exercises 3 times a week and is on a diabetic diet.