Daniel DeMarco Focused H&P#4 Ambulatory Care

Chief Complaint: Abdominal Pain since Mid-May but More Severe x 2d

 

History of Present Illness:

MP is a 34yo Male presenting to office with complaint of Abdominal Pain since Mid-May but More Severe x 2d. Patient states the intermittent pain feels “like gas.” The pain is located in the epigastric region and radiates up into the chest. Typically occurs 30min. to 1h after meals. Worse with laying down. Patient states he sometimes gets the sensation that “food is stuck.” Has tried Tums which works occasionally. Last BM yesterday and soft and nonbloody. Admits frequent belching, bloating, heartburn. Denies fevers, chills, nausea, vomiting, weight loss, anorexia.

 

Allergies: NKDA

Medications: Denies

PMH: Denies

PSH: Denies

Social History: Admits Social EtOH use. Denies tobacco use, marijuana use, other illicit drug use.

Family History: Denies

 

Review of Systems:

General: Denies fever, chills, anorexia, weight loss, weight gain

Neuro: Denies HA, trauma, LOC, seizure activity, developmental delays 

HEENT: Denies change in vision, hearing, pruritus, photo/phonophobia, neck pain, runny nose, ear pain, congestion, sore throat

CV: Denies shortness of breath, sweating, color changes with feeding, chest pain, palpitations, history of murmur, fainting, or dizziness with activity 

Respiratory: Denies wheezing, shortness of breath, cough

GI: Admits abdominal pain, belching, heartburn. Denies nausea, vomiting (bloody/bilious), diarrhea, constipation, hematemesis, hematochezia, or melena

GU: Denies dysuria, frequency, urgency, hematuria

Endo: Denies polyuria/polydipsia, heat/cold intolerance, growth pattern abnormalities

MS: Denies myalgias, arthralgias, trauma, limp, weakness

Skin: Denies rashes, bruising, petechiae

Psychiatric: Denies HI/SI, feelings of helplessness, hopelessness

 

Physical Exam:

Vital Signs:

BP: 136/86

Pulse: 102bpm

RR: 16 breaths/min

Temp: 37.3C

SpO2: 100%RA

Ht: 66.0 inches

Wt: 63kg

 

General Survey: Alert, NAD. Appears stated age.

Skin: No petechiae, masses, lesions. No jaundice, cyanosis, mottling. No rashes.

Hair: Average quantity and distribution.

Nails: Capillary refill <2s throughout.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally.

Abdomen: Nondistended. BS + and normoactive. Soft. Tender to palpation over epigastric region. No guarding, rebound tenderness. No hepatosplenomegaly. Murphy’s sign negative. No Mcburney’s point tenderness.

 

Assessment/Plan:

MP is a 34yo Male with 2.5m complaint of intermittent, postprandial epigastric abdominal pain that radiates to the chest, is worse with lying down, and described as burning that is acutely worsening consistent with GERD.

 

#GERD

– Omeprazole 20mg PO qd

– Lifestyle and Dietary Modification Discussed including avoiding triggers (caffeine, fatty foods, spicy foods) and discouraged lying down after eating

– Referral for Gastroenterology given. Patient will require work up for possible gastric ulcer, duodenal ulcer, H pylori infection

– If severe abdominal pain, fever, chills, vomiting, inability to eat or drink, go straight to ER

 

Follow-Up: prn

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student