PRAC 6531 Episodic Visit: Gastrointestinal Focused Note

Episodic/Focus Note Template

Patient Information:

Initials: H.D.            Age: 48 years old               Sex: Male               Race: Hispanic

S.

CC: “Burning sensation in my chest”

HPI: Mr. H.D. is a 48-year-old Hispanic male with a medical history of hyperlipidemia, hypothyroidism, hypertension, and Type II diabetes mellitus. He is currently experiencing abdominal discomfort, which he rates at a 5 to 6 out of 10, for the past two days. The patient reports experiencing persistent stomach discomfort for the past two days. He describes the sensation as a burning pain that originates in the mid-abdomen and extends to the middle of the chest. The patient’s pain typically starts after eating and intensifies when reclined but improves upon walking. The patient reports no symptoms of constipation or diarrhea. The individual’s most recent meal occurred at 14:00 today. The patient said that he has recently begun a daily regimen of aspirin, following the recommendation of his primary care physician.:

Location: Abdomen/Chest

Onset: 2 days ago

Character: Burning pain that originates in the mid-abdomen and extends to the middle of the chest

Associated signs and symptoms: reports no symptoms of constipation or diarrhea.

Timing: starts after eating

Exacerbating/ relieving factors: intensifies when reclined but improves upon walking

Severity: 5-6/10 pain scale

Current Medications:

• Atorvastatin (Lipitor) 40 mg once daily, preferably at night.
• Daily 100 mcg levothyroxine (SYNTHROID).
• Metformin (GLUCOPHAGE) 500 mg tablet taken twice daily.
• Aspirin 81 milligrams once daily.

Allergies: No allergies reported

PMHx: The patient has a history of diabetes mellitus, which is being managed through a combination of diet and medication. He also has hyperlipidemia, for which he is currently taking medication. Additionally, he also has hypothyroidism, which is being managed through medication.

Soc Hx: The patient occasionally consumes ETOH, drinking 2-3 cans of beer twice per week. He denies using illegal drugs and smoking.

Fam Hx: The patient said that their father has hypertension and their mother has diabetes, and both parents are still living.

ROS:

GENERAL: The patient is agreeable and willing to cooperate. Describes moderate abdominal pain, rating it at 5-6 on a scale of 10. The patient does not appear to be in any immediate distress.

HEENT: denies experiencing a headache, sore throat, or hearing loss.

SKIN: Not itchy or rash.

CARDIOVASCULAR: He reportedly felt a burning feeling on his chest when lying down.

RESPIRATORY: Denies experiencing coughing or dyspnea.

GASTROINTESTINAL: Reports of 5–6/10 stomach pain throughout the last two days. Characterized as “scorching” and “gnawing.” denies feeling sick or throwing up. The bowel pattern is unchanged.

GENITOURINARY: Disputes hematuria or dysuria.

NEUROLOGICAL: Denies localized weakness or lack of feeling.

MUSCULOSKELETAL: Denies drooping of the face, swelling of the joints, or focal weakness.

HEMATOLOGIC: No bleeding, bruising, or anemia.

LYMPHATICS: No nodes are enlarged. Absence of cervical lymphadenopathy

PSYCHIATRIC: No prior experience with anxiety or despair.

ENDOCRINOLOGIC: No notes of perspiration or sensitivity to heat or cold. Neither polydipsia nor polyuria.

ALLERGIES: There is no history of rhinitis, eczema, asthma, or hives.

O.

Physical exam:

Vital signs: oral temperature 98.3F; RR 18; non-laborious; B/P 117/59; pulse 108 (strong and regular); SpO2: 96% in ambient air;1.575 m (5′ 2′′) in height and 73.5 kg (162 lb.) body weight.

General: A&O x4, kind and helpful. No severe discomfort.

HEENT: normal cranium and atraumatic. PERRLA: lack of conjunctival erythema, moist mucous membranes, red oropharynx, and anicteric sclera.

Neck: Flexible. Absent JVD. The median of the trachea. No perceptible nodules, edema, or discomfort.

Chest/Lungs: Both sides are clear to auscultate. No crackles, rhonchi, or wheezing. no utilization of auxiliary muscles.

Heart/Peripheral Vascular: Heart rhythm and rate are regular. Not a whisper. No palpitations. There is no bilateral peripheral edema to palpate.

ABD: Pain ratings of 5–6/10. Non-tender, non-distended, and soft. BS that is overactive. Inability to feel hepatosplenomegaly

Genital/Rectal: The bladder and bowel continent.

Musculoskeletal: Typical range of movement. appropriate muscular mass for age. No joint malformations or edema.

Neuro: Focused and aware x 4. Sensation and strength unaltered.

Lymph nodes/Skin: There is no cervical lymphadenopathy. Not even erythema or rashes. Absence of lesions.

Diagnostic results: Electrocardiogram (EKG) indicates normal sinus rhythm (NSR). Results from laboratory studies indicate the following: CBC – WBC count of 9.4, H/H ratio of 14.3/41.0, and PLT count of 289. The chemistry panel results are as follows: BUN/Crea ratio is 19/0.52, and the glucose level is 117*. The Pylori serology result is negative and awaiting the pending Esophageal pH Test.

A.

Differential Diagnoses:

1. Gastroesophageal Reflux Disease: GERD refers to the regurgitation of acidic stomach contents into the esophagus (Maret-Ouda et al., 2020). The patient presents with complaints of a searing, gnawing pain in the middle of the upper abdomen that intensifies while lying down. Based on the stated symptoms, alcohol intake, and recent changes in the patient’s medication, the primary diagnosis for the patient is GERD.
2. Acute coronary syndrome: can manifest as heartburn or a bitter taste in the mouth, often occurring after meals. GERD is a frequent culprit of non-cardiac chest pain (Bhatt et al., 2022).

1. Peptic Ulcer: Burning or gnawing pain is commonly reported with this condition, typically occurring on an empty stomach, during times of stress, or after alcohol consumption. This pain is alleviated by eating (Graham & Khalaf, 2019).
2. Achalasia: is a medical condition characterized by the inability of the esophagus to transport food to the stomach properly. This occurs when the lower esophageal sphincter remains closed during swallowing, causing food to back up. Common symptoms of achalasia include vomiting unprocessed food, chest pain, heartburn, and loss of weight (Savarino et al., 2022).
3. Gastritis: is characterized by a persistent burning pain in the epigastric area, often accompanied by symptoms such as nausea, vomiting, diarrhea, or fever. It has been observed that the consumption of alcohol, nonsteroidal inflammatory drugs, and salicylates can exacerbate the pain (Rugge et al., 2020).

It is necessary to order an upper GI endoscopy to assess potential complications of GERD or other underlying issues that may be contributing to the patient’s symptoms (Maret-Ouda et al., 2020).

The treatment involves lifestyle modification and controlling gastric acid secretion through medication or surgical treatment based on the lab results (Maret-Ouda et al., 2020).

If medication fails to alleviate the patient’s condition, a referral to a specialist may be made to explore the possibility of surgery (Maret-Ouda et al., 2020).

The patient will be instructed to elevate their head while sleeping. Utilizing additional pillows can aid in preventing reflux. Consuming smaller, more frequent meals throughout the day, rather than a few large ones, has been found to support digestion and potentially reduce the occurrence of heartburn (Maret-Ouda et al., 2020).

To assess the outcome, the patient should schedule a follow-up appointment at the clinic one week after treatment.

Reflection: The case scenario outlined above presents a patient displaying symptoms of burning pain that originates in the abdomen and extends to the middle of the chest. The individual characterizes the discomfort as a persistent sensation that commences following meals, particularly when in a reclined position. These symptoms align with the diagnosis of GERD, a condition frequently observed in individuals of lower socioeconomic status and advanced age who may face challenges in accessing nutritious foods. Additional diagnostic tests, such as GI endoscopy, must be conducted before medication therapy to confirm this diagnosis (Maret-Ouda et al., 2020). Meanwhile, patients can implement the recommended lifestyle changes and adopt appropriate dietary habits to manage symptoms effectively. These may include sleeping with an elevated head and consuming small, frequent meals. The patient’s case was presented and handled suitably.

References

Bhatt, D. L., Lopes, R. D., & Harrington, R. A. (2022). Diagnosis and treatment of acute coronary syndromes. JAMA, 327(7), 662. https://doi.org/10.1001/jama.2022.0358

Graham, D. Y., & Khalaf, N. (2019). Peptic ulcer disease. In Springer eBooks (pp. 1–31). https://doi.org/10.1007/978-3-319-90761-1_63-1

Maret-Ouda, J., Markar, S. R., & Lagergren, J. (2020). Gastroesophageal reflux disease. JAMA, 324(24), 2565. https://doi.org/10.1001/jama.2020.21573

Rugge, M., Sugano, K., Sacchi, D., Sbaraglia, M., & Malfertheiner, P. (2020). Gastritis: An update in 2020. Current Treatment Options in Gastroenterology, 18(3), 488–503. https://doi.org/10.1007/s11938-020-00298-8

Savarino, E., Bhatia, S., Gyawali, C. P., Sifrim, D., Tack, J., Thompson, S. K., & Gyawali, C. P. (2022). Achalasia. Nature Reviews Disease Primers, 8(1). https://doi.org/10.1038/s41572-022-00356-8