NURS 623 SOAP note practicum adult 2 GERD.
S.O.A.P. Note
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.
S.O.A.P. Note
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.
