What are the SOAP note elements for a 52‑year‑old male with chronic bloating and belching, hypertension treated with lisinopril, occasional ibuprofen use, social alcohol use, and smoking, without alarm symptoms?

SOAP Note Elements for a 52-Year-Old Male with Chronic Bloating and Belching

Subjective

Chief Complaint:

• Chronic bloating and belching 1

History of Present Illness:

• Duration and frequency of bloating and belching symptoms 1
• Timing: Relationship to meals (postprandial worsening suggests abdominophrenic dyssynergia or food intolerance) 1, 2
• Character of belching: Frequency, force, and whether it provides relief (gastric belching is less frequent with greater force; supragastric belching is more frequent and voluntary) 1
• Associated GI symptoms: Presence or absence of constipation (51% have lactose intolerance, 60% have fructose intolerance if bloating present) 1, 2
• Bowel habit changes: Diarrhea, constipation, or alternating pattern to assess for IBS overlap (occurs in up to 50% of functional dyspepsia patients) 1
• Pain characteristics: Location (epigastric vs. diffuse), relationship to defecation (unrelated in functional dyspepsia, related in IBS) 1

Alarm Symptoms (Must Document Presence or Absence):

• Weight loss >10% (suggests malabsorption, malignancy, or serious disease) 1, 2, 3
• GI bleeding (visible blood or melena) 1, 3
• Persistent or severe vomiting (may indicate gastroparesis or obstruction) 1, 3
• Iron-deficiency anemia 1, 3
• Family history of inflammatory bowel disease or GI malignancy 1, 3

Medication History:

• Lisinopril use: Document dose and duration (ACE inhibitors generally do not cause bloating) 4, 5
• Ibuprofen use: Frequency and dose (NSAIDs can worsen GI symptoms and interact with ACE inhibitors) 6
• Other medications that may affect GI motility 3

Social History:

• Alcohol consumption: Quantity and frequency (can exacerbate bloating) 1
• Smoking history: Pack-years (smoking affects GI motility and increases GERD risk) 1
• Dietary habits: Lactose, fructose, artificial sweeteners, gluten intake 1, 2

Postinfectious Triggers:

• History of acute gastroenteritis in past 6-12 months (occurs in ~10% of functional dyspepsia cases) 1

Objective

Vital Signs:

• Blood pressure (to assess hypertension control on lisinopril) 4
• Weight and BMI (to document any weight loss) 1, 3

Physical Examination:

• Abdominal examination: Visible distention, tenderness (especially epigastric), organomegaly, masses 1
• Rectal examination: If indicated by symptoms, to assess for masses or occult blood 3
• General appearance: Signs of malnutrition or cachexia 1

Initial Laboratory Testing (Based on Age ≥25 Years and Symptoms):

• Complete blood count to exclude anemia 1, 3
• Comprehensive metabolic panel only if alarm symptoms present 1, 3
• Tissue transglutaminase IgA with total IgA levels for celiac disease screening (especially if diarrhea or weight loss present) 1, 2, 3
• H. pylori testing (breath or stool test) if age >40 years with dyspeptic symptoms 1

Assessment

Primary Diagnosis:

• Functional bloating and belching (Rome IV criteria: recurrent bloating and/or belching at least one day per week for the last 3 months, with symptom onset at least 6 months prior) 1
• Specify subtype if possible:
  • Gastric belching (involuntary, less frequent, greater force, may respond to PPI if GERD-related) 1
  • Supragastric belching (voluntary, more frequent, behavioral disorder) 1
  • Functional bloating (if bloating predominates over belching) 1

Differential Diagnoses to Consider:

• Carbohydrate intolerance (lactose 51%, fructose 60% prevalence in bloating patients) 1, 2
• IBS overlap (present in up to 50% of cases) 1
• GERD (coexists in ~33% of functional dyspepsia patients) 1
• Small intestinal bacterial overgrowth (SIBO) if high-risk features present 1, 2
• Celiac disease or nonceliac gluten sensitivity 1, 2

Risk Stratification:

• Low risk if no alarm symptoms, age 52 years, and normal physical examination (extensive imaging and endoscopy unnecessary and low-yield) 1, 3
• Higher risk requiring urgent evaluation if alarm symptoms present 1, 3

Plan

Diagnostic Approach

Initial Management (No Alarm Symptoms Present):

• No routine endoscopy or imaging indicated in absence of alarm symptoms (yield is low) 1, 3
• Consider abdominal X-ray only if aerophagia suspected (shows intestinal gas accumulation) 1, 2
• Ambulatory impedance monitoring ± high-resolution manometry (for at least 90 minutes; 24-hour preferred) to differentiate gastric from supragastric belching if belching is the predominant symptom affecting quality of life 1

Second-Line Testing (If Initial Management Fails):

• 2-week dietary restriction trial for suspected food intolerance (most economically sound approach; symptom resolution is positive predictor) 1, 2
• Hydrogen breath testing (glucose or lactulose) reserved for patients refractory to dietary restrictions with suspected lactose, fructose, or SIBO 1, 2
• Anorectal manometry if constipation present to rule out pelvic floor dyssynergia 1

Testing NOT Routinely Indicated:

• Gastric emptying studies should not be ordered for bloating alone; only consider if nausea and vomiting present 1, 3
• Whole gut motility studies should not be ordered unless treatment-refractory lower GI symptoms warrant testing for neuromyopathic disorders 1

Treatment Algorithm

First-Line: Patient Education and Dietary Modifications (3-4 Weeks Trial):

• Explain diagnosis using gut-brain axis framework and reassure about benign nature 1
• Dietary modifications:
  • Trial of lactose and fructose restriction (affects 51% and 60% of bloating patients respectively) 1, 2, 3
  • Low-FODMAP diet if carbohydrate intolerance suspected 1, 3
  • Gluten/fructan restriction if self-reported gluten sensitivity (fructans may be actual culprit) 1, 2, 3
  • Small, frequent meals with longer intervals between eating and lying down 3
• Gastroenterology dietitian referral when dietary modifications needed 1, 3

Second-Line: Behavioral and Pharmacological Interventions:

For Belching:

• If gastric belching with GERD: PPI therapy and lifestyle modifications for reflux 1
• If supragastric belching: Psychoeducation, diaphragmatic breathing (increases vagal tone, reduces stress response), and cognitive behavioral therapy 1
• Consider baclofen if related to excessive transient lower esophageal sphincter relaxations 1

For Bloating:

• Diaphragmatic breathing and central neuromodulators for abdominophrenic dyssynergia 1, 3
• Secretagogues (linaclotide, lubiprostone) if constipation present 1, 3
• Rifaximin for SIBO in high-risk patients (chronic watery diarrhea, malnutrition, systemic diseases causing dysmotility), though not FDA-approved for this indication 1, 2, 3
• Central neuromodulators (antidepressants) to reduce visceral hypersensitivity and improve psychological comorbidities 1, 3

Third-Line: Brain-Gut Behavioral Therapies:

• Hypnotherapy, cognitive behavioral therapy, or other brain-gut behavioral therapies may improve symptom burden and quality of life 1, 3

Medications to AVOID:

• Probiotics should NOT be used to treat abdominal bloating and distention 1, 3

Follow-Up Plan

• Reassess in 3-4 weeks after dietary modifications 3
• Consider specialist referral if refractory to initial management or if alarm symptoms develop 1
• Monitor ibuprofen use and consider alternative pain management given potential GI effects and interaction with lisinopril 6

Key Pitfalls to Avoid

• Do not over-test in functional bloating without alarm symptoms (extensive imaging, endoscopy, and motility testing are unnecessary and low-yield) 1, 3
• Do not assume gastroparesis based on symptoms alone (bloating, nausea, and fullness do not correlate with degree of gastric emptying delay on scintigraphy) 1, 2, 3
• Do not miss pelvic floor dysfunction if constipation present (straining with soft stool suggests dyssynergia, not just constipation) 2, 3