Family Medicine H&P 3                                       Julia Wadolowska

Date: 09/21/2021

Patient Name: MS

CC: chest/abdominal pain for one week

HPI: 38 y/o female with no PMH presenting for one week of mid back pain and chest pain. Patient states that the pain is intermittent, described as 5/10 burning/aching in the mid/upper back and lower chest and lasts for about one hour. Patient has taken Ibuprofen without much relief and admits to mild cough happening with pain. The pain occurs with meals, happening once a day usually with dinner. Patient denied having this pain before, and denies SOB, palpitations, dizziness, nausea, vomiting, diarrhea, constipation, hemoptysis, hematochezia, melena, sore throat, dysphagia.

 

PMH

Current illnesses: none

Surgeries: none

Allergies: seasonal, pollen

Medications:
– multivitamin

 

Social History

Education: college

Work/finances: accountant

Family & relationships: lives with husband and daughter

Habits/risk factors: patient denied smoking and drug use. Admits to two alcoholic drinks per week.

 

Family History

• Father, alive and well, 74
• Mother, alive and well, 70
• Brother, alive and well, 36
• Daughter, alive and well, 12

 

Review of Systems

General: admits to 15 pound weight gain over the past year due to poor diet and lack of exercise. Denies fever, chills, night sweats, fatigue, weakness, loss of appetite.

Head: Denies headache, dizziness, head trauma, unconsciousness, coma, fractures.

Mouth/throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam this year, normal.

Neck: denies localized swelling/bumps, stiffness, decreased range of motion.

Pulmonary System: admits to cough. Denies dyspnea, SOB, wheezing, hemoptysis, cyanosis, orthopnea, PND.

Cardiovascular System: admits chest pain. Denies palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur.

Gastrointestinal System:  Denies abdominal pain, nausea, vomiting, diarrhea, constipation, change in appetite, intolerance to specific foods, dysphagia, unusual flatulence or eructation, jaundice, change in bowel habits, hemorrhoids, rectal bleeding, blood in stool, flank pain.

Musculoskeletal System: admits to mid/upper back pain. Denies joint pain, deformity, swelling, redness, arthritis.

Endocrine System: denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism.

 

Physical Exam

Vital Signs:

BP: 138/86   HR: 88   RR: 16   O2 sat: 98%   Temp: 99.0 F

Weight: 205 lbs.  Height: 5’7   BMI: 32.1

General: A&O to person, place, time. Able to recall recent and past events. Well groomed, appropriately dressed, in no apparent distress.

Skin: skin is warm, moist, good turgor, non-icteric, no scars, lesions, tattoos, moles noted. No nail pitting, clubbing. Hair of average quantity and distribution.

Pharynx: well-hydrated. No injection, exudates, masses, lesions, foreign bodies. Tonsils present with no injection, exudates. Uvula pink, no edema or lesions.

Neck: trachea midline. No masses, lesions, scars pulsations. Supple, non-tender to palpation. No nuchal rigidity noted.

Thorax and lungs: chest symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxic respirations, no use of accessory muscles. Non-tender to palpation. Lungs clear to auscultation bilaterally. Chest expansion symmetrical. No adventitious sounds.

Cardiovascular: PMI in 5th ICS in midclavicular line. Carotid pulses 2+ bilaterally without bruits. RRR. S1 and S2 distinct, no S3 or S4, no murmurs. No splitting of S2 or friction rub noted.

Abdomen: non-distended and symmetric with no scars, striae, pulsations noted. Bowel sounds normoactive in all quadrants, no aortic/renal/iliac/femoral bruits heard. Non-tender to palpation throughout. No guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation. No CVA tenderness noted.

Peripheral vascular: extremities normal in color, size, temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis, or edema noted bilaterally. Capillary refill < 2 seconds throughout. No stasis changes or ulcerations noted. Varicose veins scattered throughout both lower extremities.

Musculoskeletal: 5/5 strength and FROM in all extremities. No atrophy, weakness, erythema, swelling. Non-tender to palpation.

Mental status: normal appearance and behavior, speech and language, mood, thought process and content, understands own condition, exhibits good judgment, memory and attention, and has good cognitive function.

 

 

Assessment:

40 y/o male with no PMH presenting with one month of intermittent chest/abdominal pain described as burning/aching associated with eating and sporadic cough. Patient denies SOB, dizziness, palpitations, dysphagia, nausea, vomiting, stool changes.

 

Ddx:

1. GERD
   1. Most likely since pain is described as burning in the lower chest, associated with meals.
2. Angina
   1. Less likely as patient is 39 years old with no cardiac history and risk factors. Pain is described as burning and not associated with exertion, without SOB.
3. Gastritis
   1. Possible but less likely as patient has no abdominal pain and no associated abdominal symptoms.
4. Pancreatitis
   1. Unlikely as although there’s lower chest pain that could be confused with epigastric pain radiating to back, the history and physical do not point to this diagnosis
5. Aortic dissection
   1. Mid back and lower chest pain are seen with this diagnosis but the rest of the history and physical do not point to this diagnosis

 

Plan:

• ECG to rule out ischemia
• Prescribe trial of Omeprazole 10 mg once daily to monitor symptom improvement
• Encourage to eat smaller meals, avoid spicy and acidic foods, avoid chocolate, and avoid eating within an hour of laying down
• Follow up in 2 weeks