Student Name:

Course:

Patient Name: B.N.

Date:

Time:

Ethnicity: Caucasian

Age: 41

Sex: Male

SUBJECTIVE (must complete this section)

CC: “I have a heartburn and acid reflux that keeps waking me up at night”

HPI: B.N. is a 45-year-old male patient with a history of gradually worsening gastroesophageal reflux symptoms. He presents with frequent typical episodes of heartburn following spicy or fatty meals and periodic regurgitation of sour-smelling fluid into his mouth. Onset was 3 months ago and have gradually worsened. Located in the epigastric region, with occasional radiation to the throat with a duration typically last 1–2 hours after meals or when lying down at night, with a character: A burning pain or pressure in the chest and upper abdomen. The aggravating factors have been consuming spicy, fatty, or acidic foods, as well as when bending over or lying flat and the relieving factors the use of over-the-counter antacids. Timing have been intermittently throughout the day but are most frequent post-meals and during nighttime, with a Severity of 6/10 on average, with occasional exacerbations to 8/10 during severe episodes.

· Medications: Omeprazole 20 mg daily (started 2 weeks ago)

· Previous Medical History: Hypertension (diagnosed 4 years ago) and GERD.

Allergies: Penicillin , with dizziness and flushing sensation.

Medication Intolerances: None reported

Chronic Illnesses/Major traumas: Hypertension

Hospitalizations/Surgeries: None reported

FAMILY HISTORY

· M: Alive and healthy

· MGM: Late, asthma

· MGF: Alive, GERD

· F: Alive, obesity

· PGM: died of road accident

· PGF: Alive, healthy

Social History: B.N. is an office employee with a 14-year history of reported cigarette smoking. He smokes a half pack per day and sporadic alcohol use, having two or more beers per week. He denies all illicit drug use. His food intake is fast food and coffee drinking, frequent enough to explain his gastrointestinal complaints. His habits of smoking and eating are addressed as possible aggravating factors in his illness.

REVIEW OF SYSTEMS

General: B.N is weight loss due to acid reflux during meals.

Cardiovascular: No chest pain, palpitations, or edema

Skin: No rashes, lesions, or itching

Respiratory: No cough, shortness of breath, or wheezing

Eyes: No reported vision changes, denies eye pain.

Gastrointestinal: Heartburn, regurgitation, denies vomiting, diarrhea, or constipation

Ears: No hearing loss, tinnitus, or ear pain

Genitourinary/Gynecological:

No urinary symptoms

Nose/Mouth/Throat: No nasal congestion, or dental issues, sore throat due to acid reflux.

Musculoskeletal: No joint pain, no falls.

Breast: Denies any change.

Neurological: No headaches, dizziness, or numbness

Heme/Lymph/Endo: Denies anemia or any endocrine disorder.

Psychiatric: Denies anxiety, or mood changes.

OBJECTIVE (Document PERTINENT systems only. Minimum 3)

Weight: 180lbs

Height: 5’9”

BMI: 25.9

BP:138/88mmHg

Temp: 99.2°F

Pulse: 78bpm

Resp:16/min

General Appearance: Well-nourished, alert, and oriented x3. Appears comfortable.

Skin: Smooth with no rashes, moles, red spots

HEENT: Normocephalic, PERRLA, oral mucosa pink and moist, no pharyngeal erythema or tonsillar enlargement.

Cardiovascular: Regular rhythm and rate. S1 and S2 present, no gallops or rubs were heard.

Respiratory: Lung clear to auscultation bilaterally, no wheezes, crackles or rhonchi sounds

Gastrointestinal: Bowel sound presents is 4 quadrants, Abdomen soft upon palpation.

Breast: No lumps or tenderness noted.

Genitourinary: No tenderness, no CVA pain.

Musculoskeletal: Full range of motion in all extremities, no deformities were noted.

Neurological: Alert and oriented X 4 , speech appropriated .

Psychiatric: Patient calm and answers question appropriately , no anxiety or mood change were noted

Lab Tests: CBC, CMP, and H. pylori test.

Special Tests: None at this time

DIAGNOSIS

Differential Diagnoses

1. 1- Diagnosis, (ICD 10 code): “Peptic Ulcer Disease (PUD) – K27.9”.

Peptic Ulcer Disease is a disease in which ulcers or open sores occur in the stomach or duodenal lining, usually due to Helicobacter pylori infection or long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) (Srivastav, et al., 2023). The symptoms on presentation are epigastric burning pain, nausea, and vomiting at times. ICD-10 code K27.9 is for an unspecified peptic ulcer with hemorrhage or perforation not specified. Although patient symptoms are characteristic of GERD, PUD is not excluded since both can produce upper GI distress and have some of the same symptoms such as epigastric pain. Since there are no alarm symptoms (e.g., weight loss, hematemesis), PUD is unlikely now.

2. 1- Diagnosis, (ICD 10 code): “Esophagitis – K20”

Esophagitis is inflammation of the esophagus, usually caused by acid reflux, infection, or drug-induced inflammation (Tageldin, et al.,2021). Symptoms can be chest pain, dysphagia, and heartburn. Code K20 is the ICD-10 code that is specifically used to indicate this condition. Esophagitis is listed as a differential because chronic acid reflux (such as in GERD) will cause inflammation of the esophagus. GERD, if left untreated, can lead to esophagitis and therefore is still a consideration.

Diagnosis

•

1. 1- Presumptive Primary Diagnosis (ICD 10 code): “Gastroesophageal Reflux Disease (GERD) – K21.9” (Rogers, & Eastland, 2021)

GERD happens when stomach acid chronically flows back into the esophagus, irritating and producing symptoms of heartburn, regurgitation, and epigastric pain. GERD is usually associated with lifestyle issues such as diet, smoking, and obesity. The ICD-10 code K21.9 is for GERD without esophagitis. The diagnosis fits the patient's presenting complaint of heartburn, regurgitation, and relief with antacids, and it is the highest presumptive diagnosis (Rogers & Eastland, 2021). The presumptive diagnosis is the most likely diagnosis given the patient's history, physical exam, and preliminary findings.

Plan/Therapeutics:

1. Lifestyle Modifications:

· stop consuming those meals that cause this problem such as spicy food.

· Avoid sleeping after consuming a full meal. Eat a minimum of three hours prior to sleeping in order to allow the stomach time to digest (Jallepalli, et al., 2022)

· Refraining from taking large meals. Eating several small meals will assist the patient.

· Avoid consuming alcohol or limit the amount and smoking (Jallepalli, et al., 2022).

Medications

· The patient should Continue taking Omeprazole 20 mg daily before breakfast (Rogers, & Eastland, 2021).

· Add Famotidine 20 mg HS PRN breakthrough symptoms.

1. Follow-Up: RTC in 4 weeks for re-assessment.

Diagnostics:

· If the symptoms persists, do an upper endoscopy.

Education:

· Discussed the significance of lifestyle modifications in managing GERD.

· Discussed long-term risks of untreated GERD, including Barrett’s esophagus and esophageal cancer.

· Provided smoking cessation resources and encouraged follow-through.

Student Name:

Course:

Patient Name: (Initials ONLY)

Date:

Time:

Ethnicity:

Age:

Sex:

SUBJECTIVE (must complete this section)

CC:

HPI:

Medications:

Previous Medical History:

Allergies:

Medication Intolerances:

Chronic Illnesses/Major traumas:

Hospitalizations/Surgeries:

FAMILY HISTORY (must complete this section)

M:

MGM:

MGF:

F:

PGM:

PGF:

Social History:

REVIEW OF SYSTEMS (must complete this section)

General:

Cardiovascular:

Skin:

Respiratory:

Eyes: