I need a SOAP Note for a 30 year-old Hispanic-latino man whose chief complain include frequent indigeston, stomach discomfort, nauseas, loose stools that alternate with constipation, sometimes acid reflux with certain foods like tortillas and tacos for 6 months now. He has lost 3-4 pounds. Final diagnosis Helicobacter pylori infection detected through H. Pylori Urea Breath Test done in the office.
Past medical history: Hypertension taking losartan 50 mg in the AM, under control.
Please icd 10 code needed for final and differential diagnosis.
Treatment includes:
Omeprazol 40 mg PO 30 minutes before breakfast. It should continue for 10 days after finishing antibitotics.
Amixicllin 875 mg, metronidazole 500 mg, and clarithromycin 500 mg PO 1 tablet of each one bid for 14 days.
follow up in 4-6 weeks to repeat H. pylori Urea Breath test. Fell free to add any other pertinent and necessary information.
Patient does not drink neither smokes.
Thank you


 

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