You Must Use This Template For Soap Note Attached Below

Question

You Must Use This Template For Soap Noteattached Belowsecond Attach You must use this template for Soap note (attached below)(second attach) Soap note about A patient with Gastroesophageal Reflux Disease The Chief Complaint, Patient info, HPI, Plan section, and references must all be of your own work and no copy-paste. The Main Areas of Focus that will be checked for plagiarism is Chief Complain, History of Present Illness (HPI), Assessment with Rationale and Explanation, and the Plan. All of this should be in your own words and not copy-pasted from a past note or website or book. There should be minimum likeness noted by turn it in software in these areas. The Objective and Subjective information can be from a template (Standard Documentation) and will only be looked at for content and not for plagiarism. Follow the Soap Note Rubric as a guide Use APA format and must include minimum of 2 Scholarly Citations. (no more than 5 years) Turn it in Score must be less than 10% or will not be accepted for credit, must be your own work and in your own words. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement. The Assessment and Plan should be of your own work and individualized to your made up patient. About the complementary test indicated for the patient, the results found need to be explained.

Dr. Jack HW Helper · Accepted Answer

Introduction Gastroesophageal Reflux Disease (GERD) is a common gastrointestinal disorder characterized by the reflux of stomach contents into the esophagus, leading to symptoms like heartburn and regurgitation. Managing GERD effectively requires a comprehensive approach including thorough patient history, clinical assessment, and tailored treatment plans. This paper presents a detailed SOAP note about a hypothetical patient diagnosed with GERD, emphasizing personalized evaluation and evidence-based interventions. Subjective Data The patient, a 45-year-old male, reports experiencing persistent burning chest pain, especially after meals and when lying down. He notes the sensation of acid reflux in his throat and occasional regurgitation of sour content. His symptoms have been occurring intermittently over the past three months, with increased frequency over the last few weeks. The patient admits to consuming spicy foods, caffeine, and alcohol regularly, which exacerbate his symptoms. He also reports having gained weight recently and experiences occasional cough and sore throat. His medical history includes mild hypertension, managed with lisinopril, and no prior gastrointestinal issues. Objective Data Physical examination reveals a slightly overweight male with BMI of 29. Vital signs are within normal limits. No abdominal tenderness or masses are detected. Oral examination shows mild redness of the oropharynx but no signs of ulcers or lesions. The patient’s weight, blood pressure, and respiratory status are unremarkable. No signs of anemia or malnutrition are observed. Assessment The primary diagnosis is Gastroesophageal Reflux Disease, supported by clinical symptoms and lifestyle factors. GERD occurs when the lower esophageal sphincter (LES) relaxes inappropriately, allowing gastric contents to reflux, which causes mucosal irritation and symptom manifestation. Contributing factors in this patient include obesity, dietary habits, and possibly transient LES relaxation

You Must Use This Template For Soap Note Attached Below ✓ Solved

You Must Use This Template For Soap Noteattached Belowsecond Attach

Sample Paper For Above instruction

Introduction

Subjective Data

Objective Data

Assessment

Plan

Explanation of Diagnostic Tests and Results

Conclusion

References