JACOB ABRAHAM _53YRS_ CC-BURNING CHEST DISCOMFORT _ IHUMAN CASE STUDY LATEST 2023-2024
Ihuman Jacob Abraham 58y/o
Reason for encounter: Burning chest
... [Show More] discomfort
:Questions
1. HowcanIhelpyoutoday
a. “Ivebeenhavingsomechestdiscomfort.”
2. Doyouhaveanyothersymptomsorconcernsweshoulddiscuss?
3. Whendidthepaininyourcheststart
4. Isyourchestpainprecipitatedbyexercise
5. Doesanythingmakethepaininyourchestbeterorworse
6. Wheremorepreciselyisthepaininyourchest
7. Howsevere(1-10)isthepaininyourchest a. 4-5/10
8. Doesthepaininyourchestradiatesomeplaceelse?
a. Movesupintoneck(pointingtoadamsapple)
9. Haveyouhadthepaininyourchestbefore? 10.Anychangeinyourchestpainsinceitbegan 11.Howlongdoesyourchestpainlast
a. Last30minutes 12.Howoftendoesthischestpainocur
13. Doyoudrinkalcohol?Ifsowhatdoyoudrinkandhowmanydrinksperday?
a. 1drinkpostdinner,notQnight.
14. Canyoutellmeaboutyourdiet?Whatdoyounormallyeat?
15. Doyouhaveanyproblemswithfatigue,difficultysleeping,unintentionalweightlossorgain 16.Doyouexperienceshortnessofbreath,wheezing,difficultycatchingyourbreath
17.Doyouhaveproblemswithnauseavomitingconstipationdiarrheacoffeegroundsinyourvomit 18.Hasdrinkingalcoholevercauseyouproblems?
19. Haveyoueverfeltyouneededtocutdownonyourdrinking?
20. Haveyoueverbeenannoyedatanyoneforsuggestingthatyoucutbackinyouralcoholconsumption? 21.Doyouneedanalcoholicdrinkfirsthinginthemorning?
22. Whenandwhatdidyoulastdrink?
23. Doyoupresentlyhaveheartburn,afoodoracidtasteinyourmouth? 24.Doyouhaveahistoryofheartburn?
25.Doyouhaveanyproblemswithnervousness,depression,lackofinterest,sadness… 26.Doyouhavedifficultybreathing
27.Hasanyonesuggestedthatyoushouldreducetheamountofalcoholyoudrink
:::MISSING
in PMH 1
in Etiology 1
Diagnosis: GERD
:Differential diagnosis
:Madalyn put
Unstable angina -
GERD -
Pneumonia -
Aortic dissection -
Acute coronary syndrome -
Sprain/strain -
Gastritis -
Peptic ulcer disease - Dyspepsia, functional -
:I put
- GERD
- Peptic ulcer disease
- Achalasia
- Gastritis
- Dyspepsia
- Gastroparesis Coronary artery disease -
Hiatal hernia -
Pancreatitis, chronic -
:Findings
Poor eating habits -
Alcohol use - Obesity -
Burning chest pain radiating into the neck -
Lack of exercise - [Show Less]