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GERD SOAP Note
Katelyn Hiltz
University of North Alabama
Anderson College of Nursing and Health Professions
NU 642: FNP II
Dr. Martin
4/28/2025
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SOAP Note
Subjective Information
Chief Complaint: “Stomach pain and burning in the center of my chest that goes up into my
throat and just will not get better. I am also burping all the time”
History of Present Illness: A 38-year-old male presents to the clinic c/o abdominal pain and
burning in the center of his chest that has lasted for 3 days. He states that he has never felt this
feeling before and is concerned. He states that the abdominal pain is “above his belly button” and
gets worse after he eats and when he lies down. He denies any radiation of the abdominal pain
and that it goes away after about an hour. He states that he tried taking Pepto Bismol with no
relief. He denies any fever, vomiting, or diarrhea. States that he does feel slightly nauseous. He
states that his bowel movements have been regular.
Review of Systems:
Constitutional: (-) fever, (-)fatigue, (-) weight loss
HEENT: (-) runny nose, (-) ear pain, (-)sore throat, (-) sneezing, (-)vision changes
Respiratory: (-) shortness of breath, (-) wheezing, (-)cough
Cardiovascular: (-)chest pain, (-)irregular heart rate, (-)nail color changes (+) burning in center of
chest
Gastrointestinal: (+) abdominal pain (epigastric region) (+) tenderness to epigastric region of
abdomen (+)heartburn, (+)nausea, (-)vomiting, (-)diarrhea, (-) constipation, (-)blood in stools
Genitourinary: (-) dysuria, (-) urinary frequency and urgency, (-) flank pain, (-) hematuria , (-)
nighttime voiding
Musculoskeletal: (-) joint pain, (-) joint swelling, (-) muscle pain
Neurological: (-) numbness, (-) tingling, (-) loss of muscle strength, (-)falls
Skin: (-)rash, (-)lesion, (-)discoloration
Past Medical History:
Hypertension: 2015
Past Surgical History:
No surgical history
Family History:
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Mother: HTN, GERD
Father: Hypercholesterolemia, HTN
Paternal Grandfather (deceased): HTN, Hypercholesterolemia, Stroke
Paternal Grandmother: HTN
Maternal Grandfather: T2DM, HTN, Hypercholesterolemia
Social History:
Smoking: Denies
Illicit drug use: Denies
Sexual history: Monogamous, wife of 10 years
Occupation: Contractor
ETOH: Occasional drinks at home, 4-5 drinks per week
Current Medication List:
Lisinopril 5 mg PO QD
Allergies:
Penicillin: Rash, SOB
Sulfa Drugs: Rash, SOB
Objective Information
Vital Signs: BP: 122/78 Temp: 98.4 RR: 16 Pulse: 72 O2: 99% RA Ht: 6’ 2” Wt: 296lbs
Physical Exam:
Constitutional: Alert & oriented x4. Well groomed. Normal affect.
Respiratory: Chest symmetrical, breathing unlabored. No use of accessory muscles or retractions
noted. Lungs clear on auscultation without rales, rhonchi or wheezing.
Cardiovascular: Regular rate and rhythm
Gastrointestinal: Bowel sounds present in all quadrants. Abdomen soft. (+) epigastric tenderness;
No masses, guarding, or distention noted upon palpation. (-) CVAT.
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Results of Diagnostic Tests:
CBC, CMP, Amylase, Lipase
Assessment & Plan
Primary Diagnosis:
GERD (K21.9)
Differential Diagnosis:
Cholecystitis (K81.0)
Peptic Ulcer Disease (K27.9)
Pharmacological Treatment
Omeprazole 20 mg PO QD qAM #60 0 RF
Educate the patient to take medication 30 minutes before meals
Non-pharmacological Treatment
Exercise, weight loss, and avoid trigger foods such as acidic foods, spicy foods, caffeine,
alcohol, and chocolate.
Education
GERD can be treated easily with a combination of lifestyle changes and pharmacological
therapy. Elevate HOB by 6-8 inches. Do not eat 2-3 hours before bed. Eat more frequently, small
meals rather than larger, spaced-out meals. Eat the largest meal at midday. No bedtime snacks.
Avoid tight and restrictive clothing. Assess stressors in life and ways to manage those.
Follow-up
Return to the clinic in 8 weeks to assess how the medication and lifestyle changes have affected
symptoms and overall patient condition.
Rationale
The patient’s symptoms are most consistent with those of Gastroesophageal Reflux Disease.
GERD is defined as “the backward flow of stomach or duodenal contents into the esophagus
(Dunphy & Boykin, 2023, p. 640).” GERD is a very common digestive disorder worldwide, with
an estimated prevalence of 18.1–27.8% in North America (Clarrett & Hachem, 2018). The
symptoms that are most common with GERD include heartburn that begins in the center of the
chest and then radiates up the esophagus into the throat as the acid from the stomach travels
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upwards. Belching is also a common symptom that is noted. Excessive supragastric belching is
known to make reflux symptoms worse and possibly be the cause of some reflux symptoms
(Sawada et al., 2020). The differential diagnoses that were chosen were chosen based on the
similarity of symptoms between them and GERD. Cholecystitis which is the inflammation of the
gallbladder. This condition shares the same epigastric discomfort as GERD as well as indigestion
and nausea (Dunphy & Boykin, 2023, p. 680). Peptic ulcer disease is the name for both gastric
and duodenal ulcers. The symptoms consist of epigastric pain and burning, which are noted in
the patient’s initial complaint. While belching is not included as a common symptom, the
possibility is still there. While GERD is worsened by eating, PUD is resolved by eating. (Dunphy
& Boykin, 2023, p. 645)
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References
Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal Reflux Disease (GERD). Missouri
Medicine, 115(3), 214. https://pmc.ncbi.nlm.nih.gov/articles/PMC6140167/
Dunphy, L., & Boykin, A. (2023). Primary Care : The Art and Science of Advanced Practice
Nursing (p. 640, 645, 680). F.A. Davis Company.
Sawada, A., Fujiwara, Y., & Sifrim, D. (2020). Belching in Gastroesophageal Reflux Disease:
Literature Review. Journal of Clinical Medicine, 9(10), 3360.
https://doi.org/10.3390/jcm9103360
