TOPIC: GOUT ICD10: M10.9 49 Y/O MALE , HISPANIC CHIEF

Pupil Name:

Direction:

Affected person Name: B.N.

Date:

Time:

Ethnicity: Caucasian

Age: 41

Intercourse: Male

SUBJECTIVE (must entire this portion)

CC: “I even possess a heartburn and acid reflux illness that keeps waking me up at night time”

HPI: B.N. is a 45-year-used male patient with a historical previous of frequently worsening gastroesophageal reflux symptoms. He gifts with frequent licensed episodes of heartburn following inspiring or fatty meals and periodic regurgitation of sour-smelling fluid into his mouth. Onset used to be 3 months ago and possess frequently worsened. Positioned within the epigastric effort, with occasional radiation to the throat with a length typically final 1–2 hours after meals or when lying down at night time, with a personality: A burning inconvenience or stress within the chest and greater abdominal. The irritating factors had been captivating inspiring, fatty, or acidic foods, moreover to when bending over or lying flat and the relieving factors the usage of over-the-counter antacids. Timing had been intermittently within the course of the day however are most frequent put up-meals and at some level of nighttime, with a Severity of 6/10 on realistic, with occasional exacerbations to eight/10 at some level of severe episodes.

· Drugs: Omeprazole 20 mg daily (started 2 weeks ago)

· Previous Scientific Ancient previous: Hypertension (diagnosed 4 years ago) and GERD.

Allergic reactions: Penicillin , with dizziness and flushing sensation.

Treatment Intolerances: None reported

Chronic Ailments/Predominant traumas: Hypertension

Hospitalizations/Surgeries: None reported

FAMILY HISTORY

· M: Alive and wholesome

· MGM: Slack, asthma

· MGF: Alive, GERD

· F: Alive, weight problems

· PGM: died of street accident

· PGF: Alive, wholesome

Social Ancient previous: B.N. is an location of business employee with a 14-year historical previous of reported cigarette smoking. He smokes a half pack per day and sporadic alcohol exercise, having two or extra beers per week. He denies all illicit drug exercise. His food consumption is speedy food and occasional drinking, frequent ample to reward his gastrointestinal complaints. His habits of smoking and eating are addressed as doubtless irritating factors in his illness.

REVIEW OF SYSTEMS

General: B.N is weight loss due to acid reflux illness at some level of meals.

Cardiovascular: No chest inconvenience, palpitations, or edema

Skin: No rashes, lesions, or itching

Respiratory: No cough, shortness of breath, or wheezing

Eyes: No reported imaginative and prescient adjustments, denies seek inconvenience.

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

Ears: No hearing loss, tinnitus, or ear inconvenience

Genitourinary/Gynecological:

No urinary symptoms

Nose/Mouth/Throat: No nasal congestion, or dental points, sore throat due to acid reflux illness.

Musculoskeletal: No joint inconvenience, no falls.

Breast: Denies any substitute.

Neurological: No headaches, dizziness, or numbness

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

Psychiatric: Denies dismay, or mood adjustments.

OBJECTIVE (Doc PERTINENT methods only. Minimum 3)

Weight: 180lbs

High: 5’9”

BMI: 25.9

BP:138/88mmHg

Temp: Ninety nine.2°F

Pulse: 78bpm

Resp:16/min

General Look: Properly-nourished, alert, and oriented x3. Looks happy.

Skin: Tender with no rashes, moles, red spots

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

Cardiovascular: Recurring rhythm and rate. S1 and S2 conceal, no gallops or rubs had been heard.

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

Gastrointestinal: Bowel sound gifts is 4 quadrants, Belly at ease upon palpation.

Breast: No lumps or tenderness notorious.

Genitourinary: No tenderness, no CVA inconvenience.

Musculoskeletal: Paunchy differ of motion in all extremities, no deformities had been notorious.

Neurological: Alert and oriented X 4 , speech appropriated .

Psychiatric: Affected person nonetheless and answers seek recordsdata from precisely , no dismay or mood substitute had been notorious

Lab Assessments: CBC, CMP, and H. pylori take a look at.

Particular Assessments: None right now

DIAGNOSIS

Differential Diagnoses

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

Peptic Ulcer Disease is a illness thru which ulcers or originate sores occur within the abdominal or duodenal lining, steadily due to Helicobacter pylori an infection or long-timeframe exercise of nonsteroidal anti-inflammatory medication (NSAIDs) (Srivastav, et al., 2023). The symptoms on presentation are epigastric burning inconvenience, nausea, and vomiting on occasion. ICD-10 code K27.9 is for an unspecified peptic ulcer with hemorrhage or perforation now not specified. Though patient symptoms are characteristic of GERD, PUD is now not excluded since each can produce greater GI spoil and possess about a of the identical symptoms equivalent to epigastric inconvenience. Since there usually are now not any fear symptoms (e.g., weight loss, hematemesis), PUD is now not going now.

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

Esophagitis is inflammation of the esophagus, steadily triggered by acid reflux illness, an infection, or drug-prompted inflammation (Tageldin, et al.,2021). Indicators would be chest inconvenience, dysphagia, and heartburn. Code K20 is the ICD-10 code that is particularly worn to reward this condition. Esophagitis is listed as a differential as a result of chronic acid reflux illness (equivalent to in GERD) will cause inflammation of the esophagus. GERD, if left untreated, can lead to esophagitis and due to this truth is mute a consideration.

Prognosis

•

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

GERD occurs when abdominal acid chronically flows abet into the esophagus, anxious and producing symptoms of heartburn, regurgitation, and epigastric inconvenience. GERD is continually connected with standard of living points equivalent to weight-reduction plot, smoking, and weight problems. The ICD-10 code K21.9 is for GERD without esophagitis. The diagnosis suits the patient's presenting complaint of heartburn, regurgitation, and relief with antacids, and it is the best doubtless presumptive diagnosis (Rogers & Eastland, 2021). The presumptive diagnosis is the presumably diagnosis given the patient's historical previous, bodily examination, and preliminary findings.

Idea/Therapeutics:

1. Standard of living Changes:

· dwell captivating those meals that cause this declare equivalent to inspiring food.

· Steer positive of sound asleep after captivating a plump meal. Spend no less than three hours prior to sound asleep to have the ability to permit the abdominal time to digest (Jallepalli, et al., 2022)

· Refraining from taking trim meals. Drinking several tiny meals will serve the patient.

· Steer positive of captivating alcohol or limit the quantity and smoking (Jallepalli, et al., 2022).

Drugs

· The patient could well possibly moreover mute Proceed taking Omeprazole 20 mg daily earlier than breakfast (Rogers, & Eastland, 2021).

· Add Famotidine 20 mg HS PRN step forward symptoms.

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

Diagnostics:

· If the symptoms persists, enact an greater endoscopy.

Training:

· Discussed the significance of standard of living adjustments in managing GERD.

· Discussed long-timeframe dangers of untreated GERD, at the side of Barrett’s esophagus and esophageal most cancers.

· Provided smoking finish sources and encouraged be conscious-thru.

Pupil Name:

Direction:

Affected person Name: (Initials ONLY)

Date:

Time:

Ethnicity:

Age:

Intercourse:

SUBJECTIVE (must entire this portion)

CC:

HPI:

Drugs:

Previous Scientific Ancient previous:

Allergic reactions:

Treatment Intolerances:

Chronic Ailments/Predominant traumas:

Hospitalizations/Surgeries:

FAMILY HISTORY (must entire this portion)

M:

MGM:

MGF:

F:

PGM:

PGF:

Social Ancient previous:

REVIEW OF SYSTEMS (must entire this portion)

General:

Cardiovascular:

Skin:

Respiratory:

Eyes:

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