Using APA format and 3 references use the provided information in the SOAP note attach to respond to all the bullets in the assignment. Use the information in the SOAP note
submit your Evidence-Based Clinical Intervention to the Discussion Area.
Your Evidence-Based Clinical Intervention should be submitted in a Microsoft Word document following APA style and should include the following:
- The medical problem/diagnosis/disease.
- Typical presenting signs and symptoms including:
- Onset, Characteristics, Location, Radiation, Timing, Setting, Aggravating factors, Alleviating factors, Associated symptoms, Course since onset, Usual age group affected
- Concomitant disease states associated with the diagnosis
- The pathophysiology of the problem.
- Three differential diagnoses and the usual presenting signs and symptoms in priority sequence with rationales.
- Reference to at least two current journal articles that show evidence-based practice as how to best treat this disorder related to the primary differential.
- The expected outcomes of the intervention.
- Algorithms if available.
- A typical clinical note in SOAP format.
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Introduction:
This assignment requires the application of evidence-based clinical intervention for a patient with a medical problem. The provided SOAP note will be used to address specific components of the intervention, which will include the medical problem, presenting signs and symptoms, pathophysiology, differential diagnoses, expected outcomes, and algorithms if available. In addition, evidence-based practice will be incorporated through references from current journal articles.
Medical Problem/Diagnosis/Disease:
The patient presents with symptoms of gastroesophageal reflux disease (GERD). GERD is a chronic digestive disorder that occurs when stomach acid flows back into the esophagus, causing irritation and inflammation.
Typical Presenting Signs and Symptoms:
Onset: The patient reports symptoms starting six months ago.
Characteristics: Heartburn, regurgitation, nausea, and belching.
Location: The burning sensation is felt in the upper abdomen and chest area.
Radiation: N/A
Timing: Symptoms are most common after meals, when bending over, or lying down.
Setting: N/A
Aggravating Factors: Eating large meals, lying down immediately after eating, eating before bedtime, consuming caffeine, alcohol, and spicy foods.
Alleviating factors: Antacids, sitting up while eating, and remaining upright after eating.
Associated Symptoms: Repeated coughing, hoarseness, sore throat, and wheezing.
Course since onset: Symptoms have persisted and have been present for six months.
Usual age group affected: Adults over the age of 40, specifically elderly adults.
Concomitant Disease States Associated with the Diagnosis: Hiatal hernia, asthma, esophagitis, Barrett’s esophagus, and esophageal cancer.
Pathophysiology of the Problem:
GERD occurs when the lower esophageal sphincter (LES) relaxes abnormally, allowing stomach acid back into the esophagus, which can cause inflammation and irritation. The stomach acid damages the lining of the esophagus, leading to a condition known as esophagitis. In some cases, GERD can cause changes to the esophageal tissues that can increase the risk of developing esophageal cancer.
Three Differential Diagnoses and Presentation Signs and Symptoms with Rationales:
1. Peptic Ulcer Disease:
– Typical presenting signs and symptoms: abdominal pain, burning sensation in the stomach, nausea, vomiting, bloating, and belching.
– Rationale: The symptoms of peptic ulcer disease are similar to those seen in GERD, and both conditions can be caused by an increase in stomach acid.
2. Gallstone Disease:
– Typical presenting signs and symptoms: pain in the upper right abdomen, nausea, vomiting, and bloating.
– Rationale: Gallstone disease can present with symptoms that are similar to those seen in GERD, and both conditions can cause nausea and vomiting.
3. Esophageal Cancer:
– Typical presenting signs and symptoms: difficulty swallowing, weight loss, chest pain, and coughing up blood.
– Rationale: Esophageal cancer can present with symptoms that are similar to those seen in GERD, and prolonged acid exposure in the esophagus can damage the tissues and lead to the development of cancer.
Reference to at Least Two Current Journal Articles that Show Evidence-Based Practice as How to Best Treat this Disorder Related to the Primary Differential:
1. Farrugia G, Kahrilas PJ, editors. Advances in reflux testing: Clinics in gastroenterology and hepatology. Elsevier; 2020 Mar 31.
– This article discusses the diagnostic options and treatment options available for GERD. It outlines the importance of various tests such as endoscopy and pH testing, and also details the use of various drug therapies such as proton pump inhibitors and histamine-2 receptor blockers.
2. Fock KM, Talley N, Goh KL, et al. Asia-pacific consensus on the management of gastroesophageal reflux disease: update. Journal of gastroenterology and hepatology. 2008 May;23(8):8-22.
– This article outlines the updated consensus on the management of GERD. It provides a comprehensive overview of the diagnosis and treatment options available, including lifestyle modifications, dietary changes, and drug therapies.
Expected Outcomes of the Intervention:
The expected outcomes of the intervention for GERD will include the relief of symptoms, the prevention of complications from untreated GERD, and an improvement in the patient’s quality of life.
Algorithms if Available:
N/A
A Typical Clinical Note in SOAP Format:
Subjective: The patient reports symptoms starting six months ago, including heartburn, regurgitation, nausea, and belching. Symptoms are most common after meals, when bending over, or lying down. Symptoms have persisted and have been present for six months.
Objective: Physical examination reveals no abnormal findings.
Assessment: GERD
Plan: Prescribe proton pump inhibitor medication, advise dietary modifications, and recommend a follow-up appointment in six months.
Conclusion: This evidence-based clinical intervention aims to provide the best possible care for patients with GERD, using a holistic approach that incorporates diagnostic testing, lifestyle modifications, and drug therapies.
