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
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.
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.
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