Health Assessment Check-Off Project Essay

Health Assessment Check-Off Project Essay

Physical Exam Documentation

 

Chief Complaint: “Heartburn”

History of Present Illness:

A 24-year-old Asian female patient presented with a chief complaint of heartburn, which began about four weeks ago. She experienced heartburn after meals, and the discomfort lasted 15-40 minutes. She described the heartburn as a burning discomfort that often radiated into the neck. The heartburn was sometimes accompanied by regurgitation of food in the mouth, especially at night when sleeping. She reported that the regurgitated food was acidic and would sometimes corrode her throat, causing painful swallowing. The heartburn was triggered by meals and staying in a reclined position after meals and was relieved to some degree by drinking milk. She has also been taking OTC antacids tablets to relieve the heartburn, but the relief is only temporary.

Past Medical History (Hx):

No history of chronic illnesses.

Past Surgical Hx:

Positive history of Tonsillectomy at 5 years.

Family Hx:

Positive family history of HTN and prostate cancer (maternal grandfather); stomach cancer (paternal grandmother).

Social Hx:

The patient was born and raised in Tolland County, CT. She is single and lives with her parents and two siblings. She is the 2nd born in the family. She is currently in his final college year studying Fashion and Design. She admits to smoking ½ PPD, taking 3-4 glasses of vodka (2-3) times a week, and using recreational marijuana. She goes to the gym 3-4 times a week and sleeps about 7 hours per day.

Allergies:

No drug or food allergies.

Medications:

OTC Antacids tablets to relieve heartburn.

Review of symptoms by system:

General: Denies fever, chills, fatigue, or malaise.

HEENT: Positive for painful swallowing. Negative for head trauma, visual changes, hearing loss, ear discharge, rhinorrhea, sneezing, dental pain, or sore throat.
Cardiovascular: Denies chest pain, palpitations, SOB on exertion, or edema.

Respiratory: Denies cough, sputum production, chest pain, of breathing difficulties.

GI: Positive for heart burn and food regurgitation. Denies nausea/vomiting, flatulence; abdominal pain, diarrhea, constipation, or rectal bleeding.

Physical Exam:

Vital signs: BP-112/70; HR-78; RR-20; Temp: 98.4; HT-5’3; WT-127; BMI- 22.5

General: Neat; alert; no acute distress; speech has normal rate and volume; normal gait and posture.

Cardiovascular: No edema or neck vein distension; normal heart rate and rhythm.

Respiratory: Uniform breath in and out; chest is clear on auscultation.

GI: Flat abdomen; smooth abdominal movements on respiration; no abdominal tenderness; no guarding; no abdominal masses; no organomegaly.

Assessment:

Gastroesophageal Reflux Disease (GERD): GERD was the primary diagnosis based on positive symptoms of heartburn, regurgitation of gastric contents, and painful swallowing. The patient’s heartburn was characteristic of GERD in that it occurred after meals and when lying supine (Savarino et al., 2020).

Achalasia:  Achalasia is a differential diagnosis based on positive symptoms of painful swallowing, food regurgitation, and heartburn. Dysphagia (swallowing difficulties) is the most common symptom of Achalasia (Savarino et al., 2020).

Acute Gastritis: It is characterized by gnawing or burning epigastric pain. It is sometimes accompanied by nausea and vomiting. The epigastric pain can improve or worsen with meals. Acute gastritis is a differential diagnosis based on the patient’s history of heartburn that is aggravated by meals (Azer & Akhondi, 2022).

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Treatment Plan:

Medications:  Esomeprazole 40 mg orally 30 minutes before breakfast (Katz et al., 2021).

Non-pharmacological: Elevate the head of bed; Use pillows when sleeping.

Health Education: Avoid NSAIDs, coffee, alcohol, fatty foods, and smoking (Mehta et al., 2020).  Eating at least 3 hours before bedtime.

Referral: No referral at this time. Consultation with a gastroenterologists if symptoms persist or presence of upper GI bleeding (Katz et al., 2021).

Follow-up: After four weeks to assess response to treatment.

References

Azer, S. A., & Akhondi, H. (2022). Gastritis. In StatPearls. StatPearls Publishing.

Katz, P. O., Dunbar, K. B., Schnoll-Sussman, F. H., Greer, K. B., Yadlapati, R., & Spechler, S. J. (2021). ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Official journal of the American College of Gastroenterology| ACG, 10-14309.

Mehta, R. S., Song, M., Staller, K., & Chan, A. T. (2020). Association between beverage intake and incidence of gastroesophageal reflux symptoms. Clinical Gastroenterology and Hepatology, 18(10), 2226-2233. . https://doi.org/10.1016/j.cgh.2019.11.040

Savarino, V., Marabotto, E., Zentilin, P., Furnari, M., Bodini, G., De Maria, C., … & Savarino, E. (2020). Pathophysiology, diagnosis, and pharmacological treatment of gastro-esophageal reflux disease. Expert review of clinical pharmacology, 13(4), 437-449. https://doi.org/10.1080/17512433.2020.1752664

Complete the “Health Assessment Check-Off Project” template using a patient with whom you have previously worked. Ensure that you have adequately completed the assessment steps and given a proper recommendation.

APA style is not required, but solid academic writing is expected.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

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