Patient Information
Date of encounter: 10/27/2017 1400
Patient: B. G.
Age: 33 years
Date of Birth: 05/01/1984
Race: Caucasian
Sex: Male
Insurance: Humana
Comprehensive SOAP
Laura Gomez
Source of information: Pa
...
Patient Information
Date of encounter: 10/27/2017 1400
Patient: B. G.
Age: 33 years
Date of Birth: 05/01/1984
Race: Caucasian
Sex: Male
Insurance: Humana
Comprehensive SOAP
Laura Gomez
Source of information: Patient is reporter and reliable historian.
S – SUBJECTIVE DATA
Chief complaint
Patient seeking medical attention for “having a lot of heartburn lately”.
History of present illness
Patient reports history of “occasional heartburn”, but episodes are frequent for past 6 weeks and
beginning to interfere with sleep.
● Location: Starts in epigastric region and radiates up to the throat.
● Quality: Burning sensation
● Quantity: Severe discomfort rated 7 out of 10
● Timing: Episodes occur three times a week in late evening hours, usually after dinner, and lasts
one to two hours each
● Setting or context at onset: Increase in work demands. Patient reports having to work a lot of
overtime.
● Aggravating factors: worse with consumption of beer or greasy foods and lying flat
● Relieving factors: Semi-reclined positioning and TUMS and “getting in shape”
● Associated manifestations: Abdominal “fullness”, belching and occasional small regurgitation of
stomach contents
● Self-treatment: Extra strength TUMS and sleeping with extra pillows or in his recliner
● Significant past medical history: Patient reports history of heartburn. Patient also reports history
of obesity and currently being “overweight again”. Patient verifies family history of obesity as
well.
Past medical history
● Childhood illnesses: Chickenpox as a toddler
● Adult illnesses: Obesity beginning in college, but patient reports reaching healthy weight with
diet and exercise in 2008.
● Immunizations: Up to date. Last influenza in October 2017 and last Tdap in July 2016.
● Health maintenance: Yearly physicals for work, annual eye exams and regular dental cleanings
● Injuries/Accidents: Patient reports meniscus tear playing basketball in 2009 and head laceration
from altercation in 2013.
● Hospitalizations/Surgeries: Surgery to repair meniscus tear with normal postoperative
hospitalization
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