TOPIC: TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA ICD10: E11.65 forty five

Pupil Title:

Course:

Affected person Title: B.N.

Date:

Time:

Ethnicity: Caucasian

Age: 41

Intercourse: Male

SUBJECTIVE (must complete this piece)

CC: “I devour a heartburn and acid reflux that keeps waking me up at night”

HPI: B.N. is a forty five-year-historical male affected person with a historical previous of gradually worsening gastroesophageal reflux symptoms. He provides with frequent long-established episodes of heartburn following spicy or fatty meals and periodic regurgitation of sour-smelling fluid into his mouth. Onset used to be 3 months ago and devour gradually worsened. Located within the epigastric attach, with occasional radiation to the throat with a duration typically final 1–2 hours after meals or when lying down at night, with a personality: A burning anguish or rigidity within the chest and greater abdomen. The demanding factors had been drinking spicy, fatty, or acidic meals, as properly as when bending over or lying flat and the relieving factors the utilization of over-the-counter antacids. Timing had been intermittently at some stage within the day however are most frequent post-meals and at some stage in nighttime, with a Severity of 6/10 on common, with occasional exacerbations to eight/10 at some stage in excessive episodes.

· Medications: Omeprazole 20 mg on daily foundation (started 2 weeks ago)

· Old Medical Historical previous: Hypertension (diagnosed 4 years ago) and GERD.

Hypersensitive reactions: Penicillin , with dizziness and flushing sensation.

Medicine Intolerances: None reported

Chronic Ailments/Main traumas: Hypertension

Hospitalizations/Surgical procedures: None reported

FAMILY HISTORY

· M: Alive and wholesome

· MGM: Lifeless, asthma

· MGF: Alive, GERD

· F: Alive, weight problems

· PGM: died of avenue accident

· PGF: Alive, wholesome

Social Historical previous: B.N. is an office employee with a 14-year historical previous of reported cigarette smoking. He smokes a half pack per day and sporadic alcohol spend, having two or more beers per week. He denies all illicit drug spend. His food intake is hasty food and espresso drinking, frequent enough to train his gastrointestinal complaints. His habits of smoking and eating are addressed as conceivable demanding factors in his sickness.

REVIEW OF SYSTEMS

Classic: B.N is weight loss due to the acid reflux at some stage in meals.

Cardiovascular: No chest anguish, palpitations, or edema

Skin: No rashes, lesions, or itching

Respiratory: No cough, shortness of breath, or wheezing

Eyes: No reported vision changes, denies detect anguish.

Gastrointestinal: Heartburn, regurgitation, denies vomiting, diarrhea, or constipation

Ears: No listening to loss, tinnitus, or ear anguish

Genitourinary/Gynecological:

No urinary symptoms

Nostril/Mouth/Throat: No nasal congestion, or dental complications, sore throat due to the acid reflux.

Musculoskeletal: No joint anguish, no falls.

Breast: Denies any swap.

Neurological: No complications, dizziness, or numbness

Heme/Lymph/Endo: Denies anemia or any endocrine disorder.

Psychiatric: Denies be troubled, or mood changes.

OBJECTIVE (Doc PERTINENT methods handiest. Minimum 3)

Weight: 180lbs

Top: 5’9”

BMI: 25.9

BP:138/88mmHg

Temp: ninety nine.2°F

Pulse: 78bpm

Resp:16/min

Classic Appearance: Successfully-nourished, alert, and oriented x3. Appears to be like cushty.

Skin: Aloof with no rashes, moles, purple spots

HEENT: Normocephalic, PERRLA, oral mucosa purple and moist, no pharyngeal erythema or tonsillar growth.

Cardiovascular: Recent rhythm and rate. S1 and S2 snarl, no gallops or rubs were heard.

Respiratory: Lung certain to auscultation bilaterally, no wheezes, crackles or rhonchi sounds

Gastrointestinal: Bowel sound provides is 4 quadrants, Abdomen delicate upon palpation.

Breast: No lumps or tenderness illustrious.

Genitourinary: No tenderness, no CVA anguish.

Musculoskeletal: Beefy vary of roam in all extremities, no deformities were illustrious.

Neurological: Alert and oriented X 4 , speech appropriated .

Psychiatric: Affected person restful and answers query precisely , no be troubled or mood swap were illustrious

Lab Checks: CBC, CMP, and H. pylori check.

Particular Checks: None at the moment

DIAGNOSIS

Differential Diagnoses

1. 1- Diagnosis, (ICD 10 code): “Peptic Ulcer Disease (PUD) – K27.9”.

Peptic Ulcer Disease is a illness whereby ulcers or initiating sores occur within the abdominal or duodenal lining, in total due to the Helicobacter pylori an infection or lengthy-term spend of nonsteroidal anti-inflammatory capsules (NSAIDs) (Srivastav, et al., 2023). The symptoms on presentation are epigastric burning anguish, nausea, and vomiting at cases. ICD-10 code K27.9 is for an unspecified peptic ulcer with hemorrhage or perforation no longer specified. Despite the indisputable truth that affected person symptoms are attribute of GERD, PUD is no longer excluded since both can assemble greater GI anguish and devour just some of the same symptoms similar to epigastric anguish. Since there don’t appear to be any apprehension symptoms (e.g., weight loss, hematemesis), PUD is unlikely now.

2. 1- Diagnosis, (ICD 10 code): “Esophagitis – K20”

Esophagitis is irritation of the esophagus, in total prompted by acid reflux, an infection, or drug-induced irritation (Tageldin, et al.,2021). Symptoms can also moreover be chest anguish, dysphagia, and heartburn. Code K20 is the ICD-10 code that is particularly at anxiousness of snarl this situation. Esophagitis is listed as a differential on fable of continual acid reflux (similar to in GERD) will motive irritation of the esophagus. GERD, if left untreated, can lead to esophagitis and subsequently is restful a consideration.

Diagnosis

•

1. 1- Presumptive Main Diagnosis (ICD 10 code): “Gastroesophageal Reflux Disease (GERD) – K21.9” (Rogers, & Eastland, 2021)

GERD occurs when abdominal acid chronically flows aid into the esophagus, demanding and producing symptoms of heartburn, regurgitation, and epigastric anguish. GERD is in total associated with everyday life complications similar to weight loss program, smoking, and weight problems. The ICD-10 code K21.9 is for GERD without esophagitis. The diagnosis fits the affected person's presenting grievance of heartburn, regurgitation, and aid with antacids, and it’s the superb presumptive diagnosis (Rogers & Eastland, 2021). The presumptive diagnosis is the perchance diagnosis given the affected person's historical previous, physical examination, and preliminary findings.

Thought/Therapeutics:

1. Each day life Adjustments:

· stay drinking those meals that motive this subject similar to spicy food.

· Steer certain of drowsing after drinking a fleshy meal. Spend as a minimal three hours prior to drowsing in snarl to enable the abdominal time to digest (Jallepalli, et al., 2022)

· Refraining from taking immense meals. Eating quite lots of tiny meals may perchance assist the affected person.

· Steer certain of drinking alcohol or restrict the amount and smoking (Jallepalli, et al., 2022).

Medications

· The affected person may perchance restful Continue taking Omeprazole 20 mg on daily foundation prior to breakfast (Rogers, & Eastland, 2021).

· Add Famotidine 20 mg HS PRN breakthrough symptoms.

1. Follow-Up: RTC in 4 weeks for re-overview.

Diagnostics:

· If the symptoms persists, develop an greater endoscopy.

Education:

· Mentioned the importance of everyday life changes in managing GERD.

· Mentioned lengthy-term risks of untreated GERD, including Barrett’s esophagus and esophageal most cancers.

· Provided smoking discontinuance sources and encouraged practice-by.

Pupil Title:

Course:

Affected person Title: (Initials ONLY)

Date:

Time:

Ethnicity:

Age:

Intercourse:

SUBJECTIVE (must complete this piece)

CC:

HPI:

Medications:

Old Medical Historical previous:

Hypersensitive reactions:

Medicine Intolerances:

Chronic Ailments/Main traumas:

Hospitalizations/Surgical procedures:

FAMILY HISTORY (must complete this piece)

M:

MGM:

MGF:

F:

PGM:

PGF:

Social Historical previous:

REVIEW OF SYSTEMS (must complete this piece)

Classic:

Cardiovascular:

Skin:

Respiratory:

Eyes:

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