iHuman Case Study - Jacob Abraham 58yrs Old Male - CC Burning chest discomfort

iHuman Case Study - Jacob Abraham 58yrs Old Male - CC: Burning chest discomfort Ihuman Jacob Abraham 58y/o Reason for encounter: Burning chest discomfort :Questions 1. HowcanIhel py out oday a. “ I v ebeenhavi ngsomec hestdi scomf or t . ” 2. Doy ouhav eanyot hers ympt omsorconcer nsweshoul ddi sc uss ?

3. Whendi dt hepai ni ny ourc hestst ar t 4. I sy ourc hestpai npr eci pi t at edbyex er c i se 5. Doesanyt hi ngmak et hepai ni ny ourc hestbet erorwor se 6. Wher emor epr ec i sel yi st hepai ni ny ourc hest 7. Howsev er e( 110)i st hepai ni ny ourc hest a. 45/ 10 8. Doest hepai ni ny ourc hestr adi at esomepl aceel se ? a. Mov esupi nt oneck( poi nt i ngt oadamsappl e) 9. Hav ey ouhadt hepai ni ny ourc hestbef or e ?

10.Anyc hangei ny ourc hestpai nsi ncei tbegan 11.Howl ongdoesy ourc hestpai nl ast a. Last30mi nut es 12.Howof t endoest hi sc hestpai nocur 1 3 . Doy oudr i nkal cohol ?I fsowhatdoy oudr i nkandhowmanydr i nksperday? a. 1dr i nkpostdi nner ,notQni ght .

1 4 . Cany out el lmeabouty ourdi et ?Whatdoy ounor mal l yeat ?

1 5 . Doy ouhav eanypr obl emswi t hf at i gue,di ffic ul t ysl eepi ng,uni nt ent i onalwei ghtl ossorgai n 16.Doy ouex per i enceshor t nessofbr eat h,wheezi ng,di ffic ul t ycat c hi ngy ourbr eat h 17.Doy ouhav epr obl emswi t hnauseav omi t i ngconst i pat i ondi ar r heacoffeegr oundsi ny ourv omi t 18.Hasdr i nki ngal coholev erc ausey oupr obl ems ?

1 9 . Ha v ey ouev erf el ty ouneededt oc utdownony ourdr i nki ng?

2 0 . Ha v ey ouev erbeenannoy edatany onef orsuggest i ngt haty ouc utbacki ny oural coholconsumpt i on?

21.Doy ouneedanal cohol i cdr i nkf r isthi ngi nt hemor ni ng?

2 2 . Whenandwha tdi dy oul astdr i nk ?

2 3 . Doy oupr es ent l yhav ehear t bur n,af oodorac i dt ast ei ny ourmout h?

24.Doy ouhav eahi st or yofhear t bur n?

25.Doy ouhav eanypr obl emswi t hner v ousness,depr essi on,l ackofi nt er est ,sadness…

26.Doy ouhav edi ffic ul t ybr eat hi ng 27.Hasany onesugges t edt haty oushoul dr educet heamountofal coholy oudr i nk

:::MISSING in PMH 1 in Etiology 1 Diagnosis: GERD :Differential diagnosis :Madalyn put Unstable angina GERD Pneumonia Aortic dissection Acute coronary syndrome Sprain/strain -

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Gastritis

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Peptic ulcer disease

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Dyspepsia, functional :I put -

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GERD Peptic ulcer disease Achalasia Gastritis Dyspepsia Gastroparesis

Coronary artery disease Hiatal hernia Pancreatitis, chronic

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:Findings Poor eating habits Alcohol use Obesity Burning chest pain radiating into the neck Lack of exercise

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correct, found-

correct, found.P.E BP: 130/ 84, laying Pulse: 88 RR: 16

correct, found-

correct, found-

:Problem Statement J.A. is a 58 y/o male presenting with a burning chest discomfort. Rating pain 4-5/10, with pain that radiates into the neck (around the Adam's apple), lasting 30 minutes. Denies taking medication for discomfort, denies medical hx. Confirms poor eating habits, obesity, alcohol use 3 drinks/wk, and lack of .exercise :Madalyn

:Katie

:Madalyn

:I put

:Madalyn

:I put

barium swallow, cardiac catheterization, cardiac stress test, CBC, CMP, coronary angiogram cath, ) endoscopy, H pylori antibiodies, H pylori stool antigen, stomach biopsy, and pancreas biopsy not (recommended

:SOAP :Lifestyle changes Lose weight Avoid fatty foods, caffeinated and alcoholic beverages, avoid peppermint Avoid large meals, eat meals slowly Do not smoke, do not lie down immediately after meals, elevate the HOB when laying down :Medications Antacids: Tums Pepcid -

PPIs: Prilosec, Nexium, Protonix Reglan :If pain persists Endoscopy, pH testing, and/or esophageal manometry may be done -

I put: “more likely” for question 9/12

Correct, found

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Correct, found

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