Identifying Data: 

Full Name: Mrs. MA

Address: Jamaica, NY

Date of Birth: XX/XX/1966

Date & Time: 04/25/24 12PM

Location: Jamaica, Queens

Religion: Christian 

Source of Information: Self

Reliability: Reliable 

Source of Referral: Self 

Mode of Transportation: Self 

 

Chief Complaint: “heartburn” x 1 week 

History of Present Illness: 

A 58 year old female with PMHx of hypertension and hyperlipidemia presents to the clinic complaining of heartburn and chest pain that began 1 week ago. Patient states the pain is a nonradiating, intermittent, burning sensation that is often triggered by eating. The pain is nonexertional and non radiating. She has tried antacids to alleviate her symptoms, as well as drinking cold milk. She has had episodes of this in the past that resolved with milk and antacids, but this pain seems to persist. She also reports an episode of regurgitation after laying down shortly after eating. Denies fever, chills, shortness of breath, nausea, vomiting, diarrhea, constipation, palpitations. Denies sick contacts or recent travel. 

Past Medical History: 

Present Illnesses – Hypertension and Hyperlipidemia

Immunizations: Fully up to date

Childhood illnesses: None 

 

Past Hospitalizations: 

None

 

Past Surgical History:  

Breast lumpectomy, 2002

 

Medications: 

Amlodipine – 10 mg, once daily

Atorvastatin – 20 mg, once daily 

Multivitamin

 

Allergies: 

Shellfish and treenuts 

 

Family History: 

Mother – alive with HTN, DM, Hyperlipidemia 

Father – not present

5 siblings – alive and well 

Maternal Grandmother – deceased

Maternal Grandfather – deceased

Paternal Grandmother –  deceased 

Paternal Grandfather –  deceased

2 children – alive and well 

 

Social History: 

Ms. MA is a female living in her house with her spouse and two children. She is currently working as an ophthalmic technician. 

Habits: Denies smoking. Denies smoking marijuana recreationally. Denies alcohol intake. Denies illicit drug use. Endorses coffee consumption, 8 oz per day.

Travel: Denies recent travel.  

Diet: Admits to a poorly balanced diet, mainly consisting of fried, fast foods. 

Exercise: Denies regular exercise daily but intends to increase that in this upcoming year 

Safety measures: Admits to using seatbelt in moving vehicles. 

Sexual history: Reports being sexually active with one partner, her husband. Denies history of STIs.

 

Review of Systems:

General – Denies weight loss, fever, malaise, weight change, or night sweats.

Skin, hair, nails – Denies pain, pruritus, discoloration, excessive sweating, skin changes, and hair changes.

Head – Denies headache, dizziness, trauma, fainting, and Hx of vertigo.

Eyes – Denies discharge, diplopia, eye pain, visual changes, and photophobia. Last eye exam: 5 months ago.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids. 

Nose/Sinuses – Denies sinus pressure, epistaxis, nasal congestion, discharge, swelling.  

Mouth/Throat – Denies dysphagia, sore throat, hoarseness, cough. Last dental exam: 5 months ago.

Neck – Denies pain with movement, stiffness, swollen glands and trouble swallowing.  

Breasts – Denies skin changes, lumps, nipple discharge. 

Pulmonary System – Denies cough, SOB, DOE, wheezing, hemoptysis or cyanosis. 

Cardiovascular System – Denies chest pain, palpitations, edema. Last EKG: 1 year ago.

Gastrointestinal System – Reports heartburn/regurgitation. Denies abdominal pain, diarrhea, vomiting, loss of appetite, hemorrhoids, constipation, rectal bleeding. 

Genitourinary System – Denies flank pain, frequency, oliguria, urgency, nocturia, incontinence.

Sexual History – Admits to being currently sexually active. Denies history of STIs. 

Nervous – Denies dizziness, sensory disturbances, paresthesia, or changes in cognition/mental status. 

Musculoskeletal system – Denies swelling/stiffness, joint pain, muscle soreness, reduced mobility. Denies tenderness to palpation and erythema. 

Peripheral vascular system – Denies pins and needles, edema, calf pain, varicosities, cyanosis. 

Hematological System – Denies Hx of DVT/PE, lymph node enlargement, blood transfusions, anemia, clotting.

Endocrine system – Denies diabetes, heat or cold intolerance, excessive hunger/thirst.

Psychiatric – Denies changes in mood, suicidal ideations, irritability, and changes in eating habits.

 

Physical 

General: Well groomed female, appearing as her stated age of 58 years, with medium build. She appears awake, alert, oriented to person, place, time and situation. She is cooperative and appears to be a reliable source of information. She is in no acute distress.

Vital Signs: 

BP: Seated – (R) 135/84

R: 16 breaths/min, unlabored 

P: 79 beats/min, regular rhythm

T: 98.7 (Tympanic)

O2 Sat: 100%, room air 

Height: 5’1 inches     Weight: 145 lbs      BMI:  27.4

 

Skin, Hair, Nails, Head:

Skin: Warm and moist. No discoloration. Good turgor. No tattoos, no masses, no bruises, no ulcerations on upper/lower extremities. No visible scarring. 

Hair: Regular quantity, even distribution. Color is dark brown, and the texture is normal. No visible dandruff or lice.

Nails: No clubbing, pitting, signs of infection. Presence of lunula on all nails. Capillary refill < 2 seconds in upper extremities.

Head: Normocephalic, atraumatic, non-tender to palpation. 

 

Eyes:

Eyes appear symmetrical. Eye lashes are well distributed. No strabismus, lid lag, or ptosis noted. Sclera white with no jaundice, cornea clear with no signs of abrasion or nodules. Conjunctiva is clear with no foreign bodies. 

 

Mouth/Neck/Pharynx

Lips: Pink, moist, no cyanosis or edema. 

Buccal Mucosa: Pink, well hydrated, no masses, ulcerations, or leukoplakia.

Palate: Pink, well hydrated, no scars or ulcerations present.

Teeth: Normal dentition, no dental caries present, no plaque buildup.

Gingivae: Moist, with no bleeding, ulcerations, hyperplasia, or discoloration. 

Tongue: Pink, well papillated. Symmetrical with normal texture. 

Oropharynx: Well hydrated, no exudates, masses, or foreign bodies. Uvula pink, midline elevation, no ulcerations. 

Neck: Trachea midline. No masses, scars or pulsations noted. Non-tender to palpation.

 

Thorax/Lungs

Clear to auscultation. Chest was symmetrical with no signs of deformities or trauma. Respirations were unlabored and no accessory muscle use was noted. No tenderness to palpation.

 

Heart

Regular rate and rhythm. Distinct S1/S2 with no murmurs, splitting, friction rubs, or S3/S4 appreciated. Carotid pulses are 2+ bilaterally, no bruits present. 

 

Abdomen

Normoactive bowel sounds in all four quadrants with no bruits or pulsations appreciated. Abdomen is soft, symmetrical, and nondistended. No ecchymosis, rebound, or guarding. No CVA tenderness. 

Neuro Exam 

Mental Status: A&O x3, cooperative, thoughts & speech coherent.

 

Differential Diagnosis

• GERD

• Gastritis

• Peptic Ulcer Disease

• Myocardial Infarction

 

Assessment

A 58 year old female with PMHx of HTN and hyperlipidemia complains of heartburn and regurgitation for 1 week. Patient reports previous episodes of this that were resolved with milk and antacids but this pain persists. Patient is afebrile and non-toxic. Physical exam is unremarkable. 

 

Plan

• EKG
• Initiate trial of PPI – Omeprazole 20 mg, once daily before meals
• Will refer to GI if symptoms persist despite PPI use. 

 

Results

• EKG: normal sinus rhythm 

 

Patient Education

• Gastroesophageal reflux disease is when stomach acid flows back into the food pipe (esophagus), causing symptoms like heartburn and chest pain. 
• Avoid trigger foods (spicy, fatty, acidic), large meals, caffeine, alcohol, smoking, and lying down shortly after eating. 
• Lifestyle modifications including healthy eating and weight loss can curb GERD symptoms.
• Elevate the head of bed or use extra pillows to avoid nighttime reflux.
• Follow up in 4 weeks via televisit.