Name:
Professor Lydia Albuquerque
William Paterson University
NUR-6001
October 4 ,
, GI Model SOAP
SUBJECTIVE
CC: ”I’ve been having this stomach pain for a while . It keeps coming back and it really starting to
bother me.”
HPI: Ms. Tina jones is 28 y.o African American female , with complaints of upper stomach pain
and discomfort usually after eating .Patient reports her pain is “in my upper stomach, below my
breastbone in the middle, it feels like heartburn, but if its bad it sharper than that”. Patient
denies abdominal tenderness associated with pain. Patient report that the pain began about a
month and has increased gradually . Patient states that the pain began “Probably at least a
month ago, maybe longer. It started out really minor, so it took me a while to realize it was
getting bad “.Patient reports the pain happens every day , worsening pain 3-4 times a week.
Patient report pain is a 5/10 on numeric scale ,after consumption of food. Patient reports the
pain is more serve after consumption of a large meal and spicy food, bending over and when
lying supine . Patient reports the duration of pain sometimes last a few hours after meals.
Patient states” I feel best in between meals and sitting up on the couch seem to help. And
sometimes I take an antacid. Patient report partial pain relief after taken antacids. States “I
start with two and then I chew a couple more if I need to. The bottle says I can have up to four”.
Patients report noticing a increase in burping after meals . Patient consumes diet soda daily .
Patient report a decreases appetite due to her stomach pain . Patient denies nausea, vomiting
constipation and diarrhea.
PMH:
• Asthma: childhood onset 2 ½ years old, currently manage symptoms with albuterol
inhaler. Triggers: exposure to cat dander, and dust, last asthma related hospitalization
was during high school, inhaler last used 1 week ago per patient
• Diabetes Mellitus II: Diagnosis at 24, previous too metformin stopped taking 3 years ago
because it made her gassy and sick. Doesn’t do blood glucose monitoring cause its
aggravating
• Hypertension: Discuss at prior visit, diet and social lifestyles changes suggested
PSH: No surgeries
Medications:
• Tums(Antacid)2-4 chewable tablets PO PRN
• Flovent(Fluticasone) 110 mcg -Daily use, 2 puffs twice a day , last use today
• Proventil( Albuterol)90 mcg -Rescue inhaler2 puffs , prn , last used over 1 month ago
• Tylenol 500 -1000mg PRN for headaches
Professor Lydia Albuquerque
William Paterson University
NUR-6001
October 4 ,
, GI Model SOAP
SUBJECTIVE
CC: ”I’ve been having this stomach pain for a while . It keeps coming back and it really starting to
bother me.”
HPI: Ms. Tina jones is 28 y.o African American female , with complaints of upper stomach pain
and discomfort usually after eating .Patient reports her pain is “in my upper stomach, below my
breastbone in the middle, it feels like heartburn, but if its bad it sharper than that”. Patient
denies abdominal tenderness associated with pain. Patient report that the pain began about a
month and has increased gradually . Patient states that the pain began “Probably at least a
month ago, maybe longer. It started out really minor, so it took me a while to realize it was
getting bad “.Patient reports the pain happens every day , worsening pain 3-4 times a week.
Patient report pain is a 5/10 on numeric scale ,after consumption of food. Patient reports the
pain is more serve after consumption of a large meal and spicy food, bending over and when
lying supine . Patient reports the duration of pain sometimes last a few hours after meals.
Patient states” I feel best in between meals and sitting up on the couch seem to help. And
sometimes I take an antacid. Patient report partial pain relief after taken antacids. States “I
start with two and then I chew a couple more if I need to. The bottle says I can have up to four”.
Patients report noticing a increase in burping after meals . Patient consumes diet soda daily .
Patient report a decreases appetite due to her stomach pain . Patient denies nausea, vomiting
constipation and diarrhea.
PMH:
• Asthma: childhood onset 2 ½ years old, currently manage symptoms with albuterol
inhaler. Triggers: exposure to cat dander, and dust, last asthma related hospitalization
was during high school, inhaler last used 1 week ago per patient
• Diabetes Mellitus II: Diagnosis at 24, previous too metformin stopped taking 3 years ago
because it made her gassy and sick. Doesn’t do blood glucose monitoring cause its
aggravating
• Hypertension: Discuss at prior visit, diet and social lifestyles changes suggested
PSH: No surgeries
Medications:
• Tums(Antacid)2-4 chewable tablets PO PRN
• Flovent(Fluticasone) 110 mcg -Daily use, 2 puffs twice a day , last use today
• Proventil( Albuterol)90 mcg -Rescue inhaler2 puffs , prn , last used over 1 month ago
• Tylenol 500 -1000mg PRN for headaches
