iHuman Case Study - Jacob Abraham 58yrs Old Male - CC: Burning chest discomfort Download To Score A 

Ihuman Jacob Abraham

58y/o

Reason for encounter: Burning chest discomfort

 :Questions

1. How can I help you today

a. “Ive been having some chest discomfort.”

2. Do you have any other symptoms or concerns we should discuss?

3. When did the pain in your chest start

4. Is your chest pain precipitated by exercise

5. Does anything make the pain in your chest better or worse

6. Where more precisely is the pain in your chest

7. How severe (1-10) is the pain in your chest

a. 4-5/10

8. Does the pain in your chest radiate someplace else?

a. Moves up into neck (pointing to adams apple)

9. Have you had the pain in your chest before?

10. Any change in your chest pain since it began

11. How long does your chest pain last

a. Last 30 minutes

12. How often does this chest pain occur

13. Do you drink alcohol? If so what do you drink and how many drinks per day?

a. 1 drink post dinner, not Qnight.

14. Can you tell me about your diet? What do you normally eat?

15. Do you have any problems with fatigue, difficulty sleeping, unintentional weight loss or gain

16. Do you experience shortness of breath, wheezing, difficulty catching your breath

17. Do you have problems with nausea vomiting constipation diarrhea coffee grounds in your vomit

18. Has drinking alcohol ever cause you problems?

19. Have you ever felt you needed to cut down on your drinking?

20. Have you ever been annoyed at anyone for suggesting that you cut back in your alcohol consumption?

21. Do you need an alcoholic drink first thing in the morning?

22. When and what did you last drink?

23. Do you presently have heartburn, a food or acid taste in your mouth?

24. Do you have a history of heartburn?

25. Do you have any problems with nervousness, depression, lack of interest, sadness…

26. Do you have difficulty breathing

27. Has anyone suggested that you should reduce the amount of alcohol you drink

 :::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