SOAP Note Peptic Ulcer Disease PDF

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Unit 5 Discussion 1 - PUD and Anemia Discussion Prompt Scenario: The family of a 62-year-old white female call your office and ask if you can see their family member. The person being requested to be seen is known to you for the last twenty years.        

She is your former supervisor and a fellow FNP. The family reports your colleague is demonstrating signs of dementia. They note that she has not been eating much for the past few weeks reporting she has a gnawing pain in her stomach. If she does eat she reports getting 'full' very quickly. She reports feeling mildly nauseous for the last few weeks. Your friend sustained a fall injury about 9 months ago from a ladder. She shattered some teeth and developed an infection. She is under the care of an oral surgeon. You have seen a few of her patients in your practice over the last couple weeks because 'she is never in her office or available' over the last few weeks. You reflect on your last few conversations with your colleague and think to yourself that you also thought she seemed 'off her game'. You recommend her family take her to Urgent Care and you convince your colleague this is in her best interest. Labs drawn at Urgent Care reveal a Hgb of 8 and HCT of 24.

Please develop a discussion that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly resources. Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion. Initial post Utilize the information provided in the scenario to create your discussion post. Construct your response as an abbreviated SOAP note ( Subjective Objective Assessment Plan). Structure your 'P' in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the 'heading' and after the ':' input N/A] Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional - any other therapies in lieu of pharmacologic intervention] Educational: health information clients need to address their presenting problem(s); health information in support of any of the 'therapeutics' identified above; information about followup care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit Consultation/Collaboration: if appropriate - collaborative 'Advanced Care Planning' with the patient/patient's care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or

referral to another provider while the patient is still in the office; Identification of any future referral you would consider making Subjective (S): The family of a 62-year old white female calls the office and requested for me to see their family member. I have a history with the patient, and she was a former supervisor and fellow FNP. The family states that the patient is demonstrating signs of dementia. The family reports that the patient says she has a gnawing pain in her stomach, feels full quickly, and nausea for the last few weeks. The patient has an injury from a fall from a ladder about nine months ago, has shattered some teeth, developed an infection, and is under the care of an oral surgeon. The patient has been unable to work, and I have seen a few of her patients. I recently had several conversations with the patient, where I noticed that she seemed "off her game." I have talked to the family and recommended that they take her to the Urgent Care Clinic. Objective (O): Labs were drawn at Urgent Care reveal a Hgb of 8 and HCT of 24. Assessment (A): Due to the patient's pain in her stomach, nausea, loss of appetite, feeling of fullness, I suspect the patient has Peptic Ulcer Disease (PUD), with a bleeding ulcer that has lead to anemia. The anemia may also be contributing to her memory loss and early dementia symptoms. Difficulties of PUD consist of gastrointestinal bleeding (blood in stool or vomiting blood), a hole in the stomach, or an obstruction in the gastric opening. (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Patients experiencing a blockage in the gastric outlet may feel bloated, nauseous, emesis, lack of appetite, and loss of body weight. (Arcangelo et al., 2017). Plan (P): I want to determine what has caused the PUD. When the gut is functioning normally, the stomach and duodenal situation can sustain a reasonable condition where food can be digested and not damage gastric material veracity. (Arcangelo et al., 2017). The gut has many protective means to stop gastric material damage from acids and the operation of digestion. (Arcangelo et al., 2017). Helicobacter pylori and nonsteroidal anti-inflammatory drugs can disturb the process of digestion and cause an ulcer. (Arcangelo et al., 2017). I would reconcile the patients' home medications and see if she is taking any NSAID drugs that could have caused an ulcer. To test for H. pylori, I would recommend an endoscopy with biopsy for bacteria detection. (Arcangelo et al., 2017). Due to the patients' advanced age (over 50), the less invasive tests such as stool cultures, blood tests, or stool samples are not appropriate for a diagnosis. (Arcangelo et al., 2017). Therapeutics (T): If the PUD is due to NSAID use, I would recommend a different type of medication for the management of pain or if the patient is taking it for prophylaxis purposes. (Arcangelo et al., 2017). Remedies could include taking a coated tablet, taking with food, the addition of misoprostol, or changing to a COX-2 inhibitor. (Arcangelo et al., 2017). If the PUD is due to an H. pylori-related ulcer, a mixture of antibiotics and acid control regimen can be ordered. (Arcangelo et al., 2017). The overall purpose of medication treatment is to lesson indicators, decrease acid excretion, advance tissue repair, thwart relapse, and avert difficulties. (Arcangelo et al., 2017). The medication regime for PUD includes antacids, histamine 2 receptor antagonists, proton pump inhibitors, and antibiotics such as Amoxil and Flagyl. (Arcangelo et al., 2017). As far as treating the anemia, a blood transfusion should

only be administered if the patient is not stable or is presenting organ damage due to a gastrointestinal bleed. (Arcangelo et al., 2017). An iron supplement tablet is the most affordable and can supply acceptable essential iron. (Arcangelo et al., 2017). Educational (E): I would recommend that the patient stop using NSAID and encourage her to quit smoking if she is a current smoker. (Arcangelo et al., 2017). The patient should avoid hot and spicy food, limit drinking products containing caffeine and alcohol. (Arcangelo et al., 2017). Reducing stressors in life is related to a decrease in the symptom of PUD. (Arcangelo et al., 2017). A few reports have examined the use of licorice and its capability to improve gastric coating process. (Arcangelo et al., 2017). Consultation (C): Once the PUD symptoms are under control, I would recommend that the patient follow-up with a neurologist to assess her and determine if she is indeed showing signs of dementia. It would also be useful for her to see a dietician who could help her select food that are high in iron and what she should avoid preventing a relapse of the PUD exacerbations in the future. If she continued to have PUD symptoms, it would also be a good idea for her to see a gastroenterologist. Reference: Arcangelo, V. P., Peterson, A. M., Wilbur, V., Reinhold, J. A. (20161108). Pharmacotherapeutics for Advanced Practice, 4th Edition [VitalSource Bookshelf version]. Retrieved from vbk://9781496374066...