01 Jun CC – Mild “heartburn” after eating a large meal for at least 2 years
Question
Week 3 DQ 2 NR 601
S. (Subjective)
CC – Mild “heartburn” after eating a large meal for at least 2 years.
Background: Mr. M.J. is a 64-year-old patient of Hispanic descent who presents to the clinic today with concerns about epigastric and substernal pain that has gotten progressively worse over the past 3 months. He has tried over the counter products occasionally with adequate response. Three months ago, he was awakened with severe burning discomfort that extended from his mid-chest to his jaw that lasted 30 minutes before he was able to fall back to sleep. He is now experiencing these attacks about 3 times per week. He has tried avoiding large meals and is now sleeping on two pillows at night to relieve his pain which has improved his pain. The pain now occurs regularly after meals and randomly during the day. He takes antacids with each meal, but the pain still persists. Overall, he considers himself to be very healthy.
HPI:
Current Medications:
PMH:
Social Hx:
Family Hx
Focused ROS and Physical Exam:
ROS:
Objective:
Physical examination:
Primary Diagnosis:
Differential Diagnosis:
Plan:
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