NUR 600 Gi Focused Soap Note Verified Solutions
2025 Updates
SUBJECTIVE
CC - “I’ve been having stomach pains for a while. It keeps coming back and really is starting to
bother me.”
HPI - Ms. Jones is a 28-year-old African American female presenting with a one-month history
of upper abdominal pain, primarily occurring after meals. She describes the pain as a burning
sensation in the upper-middle abdomen. The pain typically arises once or twice a week but can
occur daily, especially following food intake. She rates the pain as a 5/10 in intensity and notes
that it generally subsides over time. To manage her symptoms, Ms. Jones takes over-the-counter
antacids, specifically 2-3 Tums as needed, which she reports provide some relief. Due to concern
about worsening her symptoms, she has recently reduced her food intake. Her diet typically
consists of a muffin or bread for breakfast, a sandwich with chips for lunch, and a homemade
dinner with vegetables. Snacks usually include pretzels and French fries, and she drinks diet soda
daily. She denies nausea, vomiting, diarrhea, bloating, or excess gas but does report an increase
of belching recently. Her bowel movements are normal in color, consistency, and frequency. She
also denies any fever, chills, or night sweats. She does not smoke or use illicit drugs and reports
occasional alcohol consumption when socializing with friends. She does not engage in daily
exercise.
PMH - Ms. Jones has a history of asthma and type 2 diabetes. She was diagnosed with asthma at
2½ years old and uses an albuterol inhaler as needed for symptom relief. She was diagnosed with
diabetes at age 24 but reports noncompliance with her medication regimen due to feeling
overwhelmed by the number of medications. Recently, she has been using an antacid (Tums) to
manage abdominal discomfort. She denies any history of stomach cancer, gastroesophageal
reflux disease (GERD), irritable bowel syndrome (IBS), inflammatory bowel disease (IBD),
ulcers, appendicitis, cholecystitis, or any kidney, bladder, or liver problems.
.
Medications:
Albuterol 90mcg/spray 3 puffs every 4 hours PRN for wheezing
Tums PRN for stomach pain and heartburn
Allergies: Cats and dust: itchy eyes, runny nose, wheezing, shortness of breath. Penicillin: rash,
difficulty breathing, trouble recalling exact reaction as it was during childhood. Denies seasonal
allergies.
Pertinent Family History: Patient reports grandfather with history of colon cancer. Denies
family history of GERD, stomach cancer, irritable bowel syndrome, or inflammatory bowel
disease. Denies family history of liver or kidney disease.
2025 Updates
SUBJECTIVE
CC - “I’ve been having stomach pains for a while. It keeps coming back and really is starting to
bother me.”
HPI - Ms. Jones is a 28-year-old African American female presenting with a one-month history
of upper abdominal pain, primarily occurring after meals. She describes the pain as a burning
sensation in the upper-middle abdomen. The pain typically arises once or twice a week but can
occur daily, especially following food intake. She rates the pain as a 5/10 in intensity and notes
that it generally subsides over time. To manage her symptoms, Ms. Jones takes over-the-counter
antacids, specifically 2-3 Tums as needed, which she reports provide some relief. Due to concern
about worsening her symptoms, she has recently reduced her food intake. Her diet typically
consists of a muffin or bread for breakfast, a sandwich with chips for lunch, and a homemade
dinner with vegetables. Snacks usually include pretzels and French fries, and she drinks diet soda
daily. She denies nausea, vomiting, diarrhea, bloating, or excess gas but does report an increase
of belching recently. Her bowel movements are normal in color, consistency, and frequency. She
also denies any fever, chills, or night sweats. She does not smoke or use illicit drugs and reports
occasional alcohol consumption when socializing with friends. She does not engage in daily
exercise.
PMH - Ms. Jones has a history of asthma and type 2 diabetes. She was diagnosed with asthma at
2½ years old and uses an albuterol inhaler as needed for symptom relief. She was diagnosed with
diabetes at age 24 but reports noncompliance with her medication regimen due to feeling
overwhelmed by the number of medications. Recently, she has been using an antacid (Tums) to
manage abdominal discomfort. She denies any history of stomach cancer, gastroesophageal
reflux disease (GERD), irritable bowel syndrome (IBS), inflammatory bowel disease (IBD),
ulcers, appendicitis, cholecystitis, or any kidney, bladder, or liver problems.
.
Medications:
Albuterol 90mcg/spray 3 puffs every 4 hours PRN for wheezing
Tums PRN for stomach pain and heartburn
Allergies: Cats and dust: itchy eyes, runny nose, wheezing, shortness of breath. Penicillin: rash,
difficulty breathing, trouble recalling exact reaction as it was during childhood. Denies seasonal
allergies.
Pertinent Family History: Patient reports grandfather with history of colon cancer. Denies
family history of GERD, stomach cancer, irritable bowel syndrome, or inflammatory bowel
disease. Denies family history of liver or kidney disease.
