TOPIC: MAJOR DEPRESSION DISORDER ICD10: F32.0 55 Y/O FEMALE ,

Student Name:

Direction:

Affected person Name: B.N.

Date:

Time:

Ethnicity: Caucasian

Age: 41

Intercourse: Male

SUBJECTIVE (ought to total this share)

CC: “I also delight in a heartburn and acid reflux dysfunction that keeps waking me up at evening”

HPI: B.N. is a 45-365 days-outdated male patient with a historical past of step by step worsening gastroesophageal reflux signs. He gifts with frequent identical outdated episodes of heartburn following sharp or fatty meals and periodic regurgitation of sour-smelling fluid into his mouth. Onset used to be 3 months ago and delight in step by step worsened. Located in the epigastric situation, with occasional radiation to the throat with a interval typically closing 1–2 hours after meals or when mendacity down at evening, with a persona: A burning anxiety or tension in the chest and better belly. The worrying components delight in been intelligent sharp, fatty, or acidic foods, as properly as when bending over or mendacity flat and the relieving components the expend of over-the-counter antacids. Timing delight in been intermittently all around the day but are most frequent post-meals and throughout hour of darkness, with a Severity of 6/10 on moderate, with occasional exacerbations to eight/10 throughout severe episodes.

· Medicines: Omeprazole 20 mg day-to-day (started 2 weeks ago)

· Earlier Medical Historical past: Hypertension (identified 4 years ago) and GERD.

Allergic reactions: Penicillin , with dizziness and flushing sensation.

Medication Intolerances: None reported

Continual Ailments/Well-known traumas: Hypertension

Hospitalizations/Surgeries: None reported

FAMILY HISTORY

· M: Alive and wholesome

· MGM: Slack, bronchial asthma

· MGF: Alive, GERD

· F: Alive, weight problems

· PGM: died of toll road accident

· PGF: Alive, wholesome

Social Historical past: B.N. is an put of abode of enterprise employee with a 14-365 days historical past of reported cigarette smoking. He smokes a half of pack per day and sporadic alcohol expend, having two or more beers per week. He denies all illicit drug expend. His meals consumption is rapidly meals and occasional intelligent, frequent sufficient to provide an rationalization for his gastrointestinal complaints. His habits of smoking and eating are addressed as that potentialities are you’ll presumably perhaps well imagine worrying components in his illness.

REVIEW OF SYSTEMS

Total: B.N is weight loss as a end result of acid reflux dysfunction throughout meals.

Cardiovascular: No chest anxiety, palpitations, or edema

Pores and skin: No rashes, lesions, or itching

Respiratory: No cough, shortness of breath, or wheezing

Eyes: No reported imaginative and prescient changes, denies respect anxiety.

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

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

Genitourinary/Gynecological:

No urinary signs

Nose/Mouth/Throat: No nasal congestion, or dental disorders, sore throat as a end result of acid reflux dysfunction.

Musculoskeletal: No joint anxiety, no falls.

Breast: Denies any change.

Neurological: No complications, dizziness, or numbness

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

Psychiatric: Denies scare, or mood changes.

OBJECTIVE (Document PERTINENT systems finest. Minimal 3)

Weight: 180lbs

Top: 5’9”

BMI: 25.9

BP:138/88mmHg

Temp: 99.2°F

Pulse: 78bpm

Resp:16/min

Total Appearance: Neatly-nourished, alert, and oriented x3. Looks joyful.

Pores and skin: Delicate with no rashes, moles, red spots

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

Cardiovascular: Typical rhythm and rate. S1 and S2 model, no gallops or rubs were heard.

Respiratory: Lung determined 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 eminent.

Genitourinary: No tenderness, no CVA anxiety.

Musculoskeletal: Fat fluctuate of motion in all extremities, no deformities were eminent.

Neurological: Alert and oriented X 4 , speech appropriated .

Psychiatric: Affected person level-headed and solutions search recordsdata from because it would be , no scare or mood change were eminent

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

Special Tests: None at present

DIAGNOSIS

Differential Diagnoses

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

Peptic Ulcer Disease is a illness whereby ulcers or open sores happen in the belly or duodenal lining, normally as a end result of Helicobacter pylori an infection or lengthy-term expend of nonsteroidal anti-inflammatory medication (NSAIDs) (Srivastav, et al., 2023). The signs on presentation are epigastric burning anxiety, nausea, and vomiting at times. ICD-10 code K27.9 is for an unspecified peptic ulcer with hemorrhage or perforation now no longer specified. Even even supposing patient signs are characteristic of GERD, PUD is now no longer excluded since both can invent higher GI injury and delight in a pair of of the identical signs akin to epigastric anxiety. Since there don’t seem like any scare signs (e.g., weight loss, hematemesis), PUD is now no longer going now.

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

Esophagitis is inflammation of the esophagus, normally precipitated by acid reflux dysfunction, an infection, or drug-induced inflammation (Tageldin, et al.,2021). Signs would possibly presumably perhaps well even be chest anxiety, dysphagia, and heartburn. Code K20 is the ICD-10 code that is specifically passe to model this situation. Esophagitis is listed as a differential as a end result of power acid reflux dysfunction (akin to in GERD) will trigger inflammation of the esophagus. GERD, if left untreated, can lead to esophagitis and therefore is silent a consideration.

Prognosis

•

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

GERD happens when belly acid chronically flows encourage into the esophagus, aggravating and producing signs of heartburn, regurgitation, and epigastric anxiety. GERD is normally related to conventional of living disorders akin to food regimen, smoking, and weight problems. The ICD-10 code K21.9 is for GERD with out esophagitis. The diagnosis suits the patient's presenting complaint of heartburn, regurgitation, and reduction with antacids, and it is miles the supreme presumptive diagnosis (Rogers & Eastland, 2021). The presumptive diagnosis is mainly the almost certainly diagnosis given the patient's historical past, bodily exam, and preliminary findings.

Opinion/Therapeutics:

1. Standard of living Changes:

· stay intelligent these meals that trigger this difficulty akin to sharp meals.

· Steer clear of dozing after intelligent a full meal. Luxuriate in now no longer now no longer up to three hours old to dozing in yell to allow the belly time to digest (Jallepalli, et al., 2022)

· Refraining from taking huge meals. Eating several minute meals will back the patient.

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

Medicines

· The patient ought to silent Proceed taking Omeprazole 20 mg day-to-day sooner than breakfast (Rogers, & Eastland, 2021).

· Add Famotidine 20 mg HS PRN step forward signs.

1. Apply-Up: RTC in 4 weeks for 2nd look.

Diagnostics:

· If the signs persists, enact an higher endoscopy.

Training:

· Discussed the importance of standard of living changes in managing GERD.

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

· Equipped smoking halt resources and encouraged notice-thru.

Student Name:

Direction:

Affected person Name: (Initials ONLY)

Date:

Time:

Ethnicity:

Age:

Intercourse:

SUBJECTIVE (ought to total this share)

CC:

HPI:

Medicines:

Earlier Medical Historical past:

Allergic reactions:

Medication Intolerances:

Continual Ailments/Well-known traumas:

Hospitalizations/Surgeries:

FAMILY HISTORY (ought to total this share)

M:

MGM:

MGF:

F:

PGM:

PGF:

Social Historical past:

REVIEW OF SYSTEMS (ought to total this share)

Total:

Cardiovascular:

Pores and skin:

Respiratory:

Eyes:

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