SUBJECTIVE
CC: Patient is seen today for “gnawing epigastric pain and a bitter taste in my mouth.”
HPI: Mr. C.O. is a 45 year old African American man came with a concern of experiencing gnawing epigastric pain. Mr. C.O states that the pain gets worse after eating, and whenever he tried to sleep. He came to the clinic today for a check-up and to get his prescription refilled. He stated that some laboratory tests was done at the clinic the last time he visited three months ago before he travelled out of the country to Africa. He was first diagnosed with hypertension (HTN) and gastro esophageal reflux disease (GERD) six months ago. He was started on proton pump inhibitor and antihypertensive medication. Mr. C.O. stated that he only take his medication whenever he feels like taking it and when he is having headache or heartburn in his chest. He acknowledges having diarrhea for two days, and wakes up two to three times last night to use the bathroom.
Medications:
1. Atenolol 50 mg one tablet by mouth daily (antihypertensive)
2. Triamterene/hydrochlorothiazide 37.5/25mg one tablet by mouth daily (diuretic)
3. Omeprazole 20 mg one capsule by mouth daily (proton pump inhibitor)
4. Tylenol 500mg one tablet every six hours as needed for pain or headache (analgesic)
5. One-a-day vitamin for men one tablet by mouth daily (daily supplements)
6. Docusate sodium 100 mg one capsule by mouth daily (stool softener).
PMH – Patient has medical history of Headaches, Hypertension, and GERD. Denies any diagnoses of diabetes, heart disease, cancer, TB, thyroid problems, asthma, depression, anxiety and kidney disease.
Allergies: He is allergic to Aspirin (ASA) and Penicillin (PCN).
Medication Intolerances: Pt. denies intolerance to any medication
Chronic Illnesses/Major traumas Patient denies having any major trauma.
Hospitalizations/Surgeries: Patient was admitted at the hospital for abdominal pain with nausea and vomiting in March 2014 in Africa. Patient had left knee replacement done in 2007.
Family History
Patient’s father had type two diabetes mellitus and uncontrolled hypertension and died in March 2013, at the age of 65 of heart attack. His mother has congestive heart failure (CHF) and coronary artery disease (CAD) still alive. His two brothers has uncontrolled hypertension and coronary artery disease (CAD).
Social History
He is current smoker and occasional alcohol drinker. Patient mentioned that he works a lot of hours and his position demands a lot of stress. He smokes two packs of cigarette a day and drinks three beers a day. He is divorced with three grown up children. He lives alone in one bedroom apartment. He works at Fiesta as a cashier and goes to church occasionally. He denies any depression or psychiatric problems
ROS
General
Pt. is alert and oriented x3. No weight change noted. Denies chills, weakness and night sweats. Cardiovascular
Patient denies any chest pain or palpitations on this visit. No edema noted.
Skin
Skin is dry and intact. No rashes noted. No bruising or skin discoloration noted.
Respiratory
Patient denies any cough, wheezing, hemoptysis, dyspnea, pneumonia history and TB.
Eyes
Patient denies any visual changes, blurring and use of corrective lenses. Gastrointestinal
Epigastric pain with bitter taste in his mouth, occasional constipation, no nausea and vomiting.Denies diarrhea, hepatitis, eating disorders, hemorrhoids and ulcers.
Ears
Patient denies any ear pain, hearing loss, discharge and ringing in the ear. Genitourinary/Gynecological
Patient denies burning while urinating. Denies any change in color with urination. Denies any STD. Denies any prostrate pain or testicular pain.
Nose/Mouth/Throat
Patient denies any sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness and throat pain. Musculoskeletal
Patient denies any back pain or joint pain. Patient denies swelling, stiffness or pain. He denies any fracture history and diagnosis of osteoporosis.
Breast
Denies any pain, lumps or bumps. Neurological
Patient denies having any syncope, seizures, transient paralysis, paresthesia and black out spells. He denies any migraine headaches, irritability, nuchal rigidity and increased intracranial pressure. Patient admits to occasional headaches but no dizziness.
Heme/Lymph/Endo
Patient states he is HIV negative. He denies any blood transfusion history, night sweats, swollen glands, increased thirst and cold or heat intolerance. Denies night sweat or increased hunger. Psychiatric
Patient denies any diagnosis of depression, anxiety, sleeping difficulties, suicidal ideation/attempts.
OBJECTIVE
Weight 268 Ibs BMI 43.3 Temp 98.8 BP 160/90
Height 66 inches Pulse 96 Resp 20
General Appearance
Patient is obese, appears older than his stated age, and demonstrated discomfort by facial grimacing during interview. No difficulty walking, awake, alert and oriented X 3. Cognition is intact, well grooming and balance gait. Answers questions appropriately.
Skin
No rashes noted on skin. No bruising noted. Skin is brown, warm, dry, clean and intact. No signs of dehydration noted and patient has good skin tugor.
HEENT
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full range of motion; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm on auscultation. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds.Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
Mid-epigastric tenderness on palpation, no abdominal masses, soft and non-distended. Bowel sound present in all four quadrants. Palpation with no organomegaly noted. Tympanic percussion noted throughout, and no lateral pulsation to aortic region.No hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genitourinary
Bladder is non-distended. Testes are palpable, no masses or lesions. No uretheral discharge. (Rectal has no evidence of hemorrhoids, fissures, bleeding or masses.
Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room. Bilateral extremities with no edema, pedal pulses present, strong and palpable. Tactile sensation intact with no deformity, upper and lower extremities without limitation with range of motion (ROM).
Neurological
Patient speech is clear with good tone. Posture is erect with normal gait and stable balance.
Psychiatric
Alert and oriented.Dressed in clean slacks, shirt and pants.Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Urinalysis – Negative. Urine specific gravity is normal; no dehydration noted.
Blood work – pending
CBC with differential- pending
Stool for guaiac- negative
Special Tests
ASSESSMENT FINDINGS AND PLAN
Diagnosis: Gastroesophageal Reflux Disease (GERD): “Burning, gnawing pain in mid-epigastrium that worsens with decumbency, water brash” are common complaints seen in patients with GERD (Dains, Baumann, &Scheibel, 2012, p. 28).
Gastroespohageal reflux disease (GERD), or erosive esophagitis, is a condition regarded as a backward flow of stomach acid from the stomach into the esophagus. The lining of the stomach normally protects the organ from the acid; however, the esophagus does not have any protection. Thus, the acid damages the tissue of the esophagus and this causes many of the symptoms associated with GERD. Diagnosis of the disease can usually be done when the patient experiences the most common symptoms (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2012). The heartburn ensues within 30 to 60 minutes after eating. The pains have a propensity to upsurge when the patient eats, lies down, or exercises. These actions tend to increase the amount of acid in the stomach or place the patient in positions, which force acid into the esophagus (Lewis et al., 2012). This can lead to the painful burning sensation of heartburn which can be referred to the chest. This chest pain is also a symptom of GERD (Lewis et al., 2012). The patients sometimes report a sour taste in their mouth. Physical examination tends to reveal epigastric tenderness with palpation. “The most reliable way to detect reflux as the cause of chest pain is to correlate episodes of chest pain with results of 24-hour esophageal pH monitoring” (Dains et al., 2012, p. 93).
Differential diagnoses are
Gastroenteritis: Gastroenteritis, antibiotic-associated diarrhea, and lactose intolerance are the most common differential diagnoses for Mr. C.O (Lewis et al., 2012). Differentiating between these disorders requires a thorough history and review of systems. C.O recently travelled to Africa, was admitted in the hospital for abdominal pain, fever, and vomiting. He recently finished a course of antibiotics which could be a possible source of diarrhea. Gastroenteritis should be considered as he has had diarrhea, and fever. “Gastroenteritis can occur at any age and produces diffuse cramping pain accompanied by diarrhea, fever, nausea and vomiting: can have history of recent travels, and family members ill” (Dains et al., 2012, p. 29).
Peptic Ulcer: Physical findings can be epigastric tenderness on palpation. It occurs most a lot with gastric emptying, stress, and alcohol, and pain is steady, mild, or severe and located in epigastrium (Dains et al., 2012). Due to empty feeling, or hunger, gas trapped in the epigastric region causes chest pain that can feign unstable angina.
Irritable Bowel Syndrome (IBS): The symptoms of irritable bowel syndrome may vary depend on the severity of the problem. C.O has three classic signs of IBS: Alternating constipation and diarrhea, crampy abdominal pain, and bloating (McPhee & Hammer, 2012). IBS is a multifaceted condition; affected patients may have “decreased intestinal motility along with increased intestinal pain sensitivity, also known as visceral hyperalgesia” (McPhee & Hammer, 2012, p. 697). This visceral hypersensitivity, or syndrome, really is on the end of the bell curve for the patient with IBS.
Diarrhea: Complaints of occasional constipation, diarrhea, and abdominal pain is a common incidence in the clinic setting. It is defined as loose stools that ensue more than three times in a day. It can be frightening, in serious cases can be life threatening. This could be associated with possible infection, increased temperature and severe abdominal pain (Buttaro, Trybulski, Polgar Bailey,& Sandberg-Cook, 2013). The patient’s physical exam and some of the patient complaints correlate with this diagnosis. Thus, the patient needs more diagnostic tests.
Plan: Recommended Diagnostic Test: Upper bowel series and barium swallow to check for reflux and possible Helicobacter pylori (H. pylori) titers (Buttaro et al., 2013). Amylase and lipase to rule out perforation or pancreatitis, liver function test to rule out Hepatobiliary (Buttaro et al., 2013). Abdominal ultrasound if symptoms are severe to visualize solid organs. ECG can add objective data in evaluating chest pain, and most valuable when compared with the previous results (Buttaro et al., 2013).
Medication: Omeprazole 40mg by mouth daily, 30 minutes to one hour before food for symptom relief. It is a proton inhibitor used for short term treatment of GERD (Drugs.com, 2014). Patient was educated on possible side effects, and to read the leaflet carefully before starting the medication. Patient instructed to continue with current medications as prescribed with the exception of omeprazole 20mg that was increased to 40mg a day.
Education- Instructed patient to get his family members involved his care and compliance with his medication regimen. Advised on lifestyle modifications which include quitting smoking, limiting alcohol, avoiding fatty and spicy foods (Drugs.com, 2014). Eat foods that are rich in potassium, and include more fruits and vegetables in his diet (Drug.com, 2014). Mr. C. O was encouraged to avoid triggers such as carbonated beverages, alcohol, caffeine, spicy foods, eating late at night, decreased meal size and reduce dietary fat (Buttaro et al., 2013). Encouraged to engage in physical exercise for 30 minutes to one hour up to four times a week (Drug.com, 2014).
