Alternative Treatment for Gastrointestinal Issues Case Study

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SOAP NotePatient Initials: S.P. Age: 42 Gender: FemaleSUBJECTIVE DATAChief Complaint (CC): \"I\'ve been having stomach discomfort and problems for the past few weeks.\"History of Present Illness (HPI): 42-year-old Caucasian female presents with complaints of stomach discomfort for the last 3-4 weeks.Location: Upper abdominal regionQuality: Burning sensationQuantity or severity: Moderate to severeTiming: Began gradually about 3-4 weeks ago and has been persistent since thenSetting: Symptoms worsen post mealsFactors: Spicy foods seem to exacerbate discomfort, no relief noted with over-the-counter antacidsAssociated manifestations: Reports occasional nausea, bloating, and belchingMedications: OTC antacids as neededAllergies: No known drug allergiesPast Medical History (PMH): Hypertension, Childhood MeaslesPast Surgical History (PSH): Tonsillectomy at age 7Sexual/Reproductive History: G2P2, Menarche at age 12, regular menstrual cycles, uses birth control pillsPersonal/Social History: Non-smoker, occasional alcohol use (1-2 glasses of wine/week), no illicit drug use. Works as an accountant, mostly sedentary lifestyle.Immunization History: Flu shot last year, Tdap 10 years agoSignificant Family History: Father had peptic ulcer disease, mother has hypertensionLifestyle: Lives with husband and two children, has a moderate level of stress due to work, has a support system in placeReview of SystemsGeneral: No recent weight changes, no fatigueHEENT: Normal, no issuesRespiratory: Clear, no shortness of breath or coughCardiovascular/Peripheral Vascular: Regular rhythmGastrointestinal: As described in HPIGenitourinary: Normal, no complaintsMusculoskeletal: No joint or muscle painsPsychiatric: No anxiety, depression, or other psychiatric symptomsNeurological: Alert, oriented x3Skin: No rashes, sores, or other abnormalitiesOBJECTIVE DATAPhysical ExamVital signs: BP 130/85, HR 75, RR 16, Temp 98.6°F, Weight 150lbs, BMI 24General: Well-groomed, alert, oriented, in no distressHEENT: PERRL, EOMI, no oropharyngeal erythema or exudateChest/Lungs: Clear to auscultation bilaterallyHeart/Peripheral Vascular: S1 and S2 normal, no murmurs, regular rhythm, peripheral pulses intactAbdomen: Soft, non-tender, non-distended, positive bowel sounds, mild tenderness in the epigastric regionGenital/Rectal: DeferredMusculoskeletal: Full range of motion, no pain or swellingNeurological: Alert, cranial nerves II-XII intact, no focal deficitsSkin: Warm, dry, no rashesASSESSMENTThe primary diagnosis for this patient is H. pylori gastritis, which is supported by a positive stool sample indicating H. pylori presence (Goud et al., 2019). Guidelines emphasize the importance of testing in patients manifesting chronic gastritis symptoms (Shah et al., 2021).Differential diagnoses include:1. Gastroesophageal reflux disease (GERD): Given the patient\'s presentation with a burning sensation, bloating, and belching, GERD is a plausible diagnosis (Wilkinson et al., 2019). GERD is typically a common consideration in the context of upper gastrointestinal symptoms.2. Peptic ulcer disease (PUD): Given her family history and epigastric pain, PUD remains a possibility (Alzharani et al., 2020). An endoscopic examination might offer insights into the presence of any ulcers, further delineating the diagnosis.3. H. pylori gastritis: The patient\'s symptoms, and what could be described as chronic episodes, combined with the lab results, could also justify this diagnosis (Hall & Appelman, 2019).

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In addition to the present complaints, it would be important to account for her previous diagnosis of…

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…eradication, for example, would be effective from a clinical standpoint, but it does come with potential side effects—so this is something that would have to be talked about with the patient absolutely. Taking additional time to go into these potential side effects is helpful for the doctor-patient relationship because then the patient fully understands them, and it gives them an opportunity to voice their concerns, which is something that ought to be prioritized in future encounters. This would help with adherence to treatment, in my opinion, and also in building trust and establishing a solid relationship with the patient.The experience also reinforced the necessity of evidence-based medicine in clinical practice. My preceptor\'s commitment to an evidence-driven approach has been, as always, a good reminder of its value. Evidence directs us so that our decisions are rooted in the best available information, and so that we are offering the highest standard of care. It is an approach that seamlessly ties into a holistic model of patient care, where the patient is viewed as a person and not just as a set of symptoms. Every patient is a unique individual with their own needs, experiences, and background of family health. This is a holistic perspective, which is something that has been emphasized throughout, and it reiterates the imperative of treating not just the disease, but the individual as a whole. I am certain that keeping this….....

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