Jacob Abraham _53yrs_ Cc-Burning Chest Discomfort _ Ihuman Case Study Latest 2023-2024

JACOB ABRAHAM _53YRS_ CC-BURNING CHEST DISCOMFORT _ IHUMAN CASE STUDY LATEST 2023-2024 Ihuman Jacob Abraham 58y/o Reason for encounter: Burning chest 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 -correct, found- correct, found- .P.E BP: 130/ 84, laying Pulse: 88 RR: 16correct, found- correct, found- :Problem Statement J.A. is a 58 y/o male presenting with a burning chest discomfort. Rating pain 4-5/10, with pain that radiates into the neck (around