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Original Question
HPI: Mr. Roberts is a 45-year-old male who presents to the clinic with a CC of a burning sensation in his epigastric area that he sometimes feels in his chest and neck. He also complains of having a metallic taste in his mouth especially at night. States that he has taken TUMS for relief and prior to TUMS his discomfort is an 7/10 and after is a 4/10. Admits that the burning sensation began about 5 months ago and has been getting progressively worse. Denies weight loss, bloody stools or emesis, or painful swallowing. States that he is unable to recall if certain foods trigger the burning sensation. States that home blood pressure checks have been within normal limits. ROS: General: Denies fatigue, fever, sweats, chills, weight loss. Admits to gaining 15 lbs. since COVID. Skin: Denies pruritis, rash, lesions, or moles on skin. Eyes: Denies vision changes, burning, dryness, discharge, itching, tenderness. Denies wearing contacts or eyeglasses. Ear, Nose, & Throat: Denies hearing loss or pain. Admits to metallic taste in mouth worse at night. Denies sore throat or difficulty swallowing. Neck: Denies neck injuries or decreased ROM in neck. Respiratory: Denies cough, chest congestion, dyspnea, wheezing, asthma. Cardiovascular: Denies chest pain, SOB, palpitations. Peripheral Vascular: Denies leg pain, numbness, tingling, swelling, discoloration. Gastrointestinal: Admits to burning sensation in epigastric area and chest that radiates to neck. Admits to taking TUMS as needed for reflux. Admits to appetite being good. Denies N/V/D, constipation, abdominal pain. Bowel movement daily; soft, brown, no rectal bleeding or pain. Denies hx of colonoscopy. Genitourinary/GYN: Denies dysuria, frequency, urgency, nocturia, incontinence. States urine is clear yellow. Musculoskeletal: Denies limitations in BUE and BLE ROM. Denies joint pain and swelling. Admits to occasional lower back pain. Neurologic: Denies dizziness, weakness, tremor, memory loss, mood change, language/concentration problems. Hematologic: Denies easy bruising or bleeding. Endocrine: Denies increase in hunger, thirst, urination. Denies heat and cold intolerance. Admits to gaining 15 lbs. since this time last year. PMH: HTN: Takes 10 mg PO Amlodipine daily. Surgical Hx: Denies surgical history. FH: MGM: deceased at 79 y/o – DM, HTN, MI. MGF: deceased at age 82 y/o – HTN, CVA. PGM: deceased at age 62 y/o – Breast CA, smoker. PGF: deceased at age 69 y/o – Rheumatoid Arthritis, colon cancer at 50 years old. Mother: 82 y/o- HTN, DM, CVA, smoker Father: 84y/o – HTN, dyslipidemia, GERD, smoker Sister: 46 y/o- DM Social Hx: Current ½ pack per day smoker. Drinks 5-6 beers on Sunday when watching football. Recreational drugs: Admits to smoking marijuana from 19 y/o -30 y/o Diet and exercise: Caffeine intake: 1-2 cups coffee/day. Patient eats fast food at least 3 days per week for lunch. Drinks 1-2 coca colas daily, 3 bottled waters, occasionally juice. Typically eats dinner out 3 night/week such as beef sandwiches, hamburgers, pizza, and mexican food. Snacks on chips and sweets such as cookies and donuts. Does not exercise regularly over past year, walks his dog 3x/week for 15 minutes. Marital status: Married and lives with wife. 2 children, ages 23 and 19. Occupation: Works full-time as a warehouse supervisor. Intimate Partner Violence: Denies Spirituality: Christian, does not attend church currently. Physical exam is completed and found to be unremarkable other than pt. is obese. Height 5ft 7 in. Weight 223 lbs. BMI 34.9 Questions: What is your diagnosis for Mr. Roberts? Would you start Mr. Roberts on medication today? What education should be given to Mr. Roberts? Discuss recommended health maintenance for Mr. Roberts. Health maintenance: Which are characteristic of “alarm symptoms”? A, B, or C (pick one) A: Weight gain, lethargy, increased sweating. B: SOB, Coughing, hoarseness C: Weight loss, epigastric mass, dysphagia.
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