Student Name:

Course:

Patient Name: (Initials ONLY)

Date:

Time:

Ethnicity:

Age:

Sex:

SUBJECTIVE (must complete this section)

CC:

HPI:

Medications:

Previous Medical History:

Allergies:

Medication Intolerances:

Chronic Illnesses/Major traumas:

Hospitalizations/Surgeries:

FAMILY HISTORY (must complete this section)

M:

MGM:

MGF:

F:

PGM:

PGF:

Social History:

REVIEW OF SYSTEMS (must complete this section)

General:

Cardiovascular:

Skin:

Respiratory:

Eyes:

Gastrointestinal:

Ears:

Genitourinary/Gynecological:

Nose/Mouth/Throat:

Musculoskeletal:

Breast:

Neurological:

Heme/Lymph/Endo:

Psychiatric:

OBJECTIVE (Document PERTINENT systems only. Minimum 3)

Weight:

Height:

BMI:

BP:

Temp:

Pulse:

Resp:

General Appearance:

Skin:

HEENT:

Cardiovascular:

Respiratory:

Gastrointestinal:

Breast:

Genitourinary:

Musculoskeletal:

Neurological:

Psychiatric:

Lab Tests:

Special Tests:

DIAGNOSIS

Differential Diagnoses

· 1- Diagnosis, (ICD 10 code):

· 1- Diagnosis, (ICD 10 code):

Diagnosis

•

1- Presumptive diagnosis (ICD 10 code):

Plan/Therapeutics:

Diagnostics:

Education:

Student Name:

Course:

Patient Name: B.N.

Date:

Time:

Ethnicity: Caucasian

Age: 41

Sex: Male

SUBJECTIVE (must complete this section)

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

HPI: B.N. is a 45-year-old male patient with a history of gradually worsening gastroesophageal reflux symptoms. He presents with frequent typical episodes of heartburn following spicy or fatty meals and periodic regurgitation of sour-smelling fluid into his mouth. Onset was 3 months ago and have gradually worsened. Located in the epigastric region, with occasional radiation to the throat with a duration typically last 1–2 hours after meals or when lying down at night, with a character: A burning pain or pressure in the chest and upper abdomen. The aggravating factors have been consuming spicy, fatty, or acidic foods, as well as when bending over or lying flat and the relieving factors the use of over-the-counter antacids. Timing have been intermittently throughout the day but are most frequent post-meals and during nighttime, with a Severity of 6/10 on average, with occasional exacerbations to 8/10 during severe episodes.

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

· Previous Medical History: Hypertension (diagnosed 4 years ago) and GERD.

Allergies: Penicillin , with dizziness and flushing sensation.

Medication Intolerances: None reported

Chronic Illnesses/Major traumas: Hypertension

Hospitalizations/Surgeries: None reported

FAMILY HISTORY

· M: Alive and healthy

· MGM: Late, asthma

· MGF: Alive, GERD

· F: Alive, obesity

· PGM: died of road accident

· PGF: Alive, healthy

Social History: B.N. is an office employee with a 14-year history of reported cigarette smoking. He smokes a half pack per day and sporadic alcohol use, having two or more beers per week. He denies all illicit drug use. His food intake is fast food and coffee drinking, frequent enough to explain his gastrointestinal complaints. His habits of smoking and eating are addressed as possible aggravating factors in his illness.

REVIEW OF SYSTEMS

General: B.N is weight loss due to acid reflux during meals.

Cardiovascular: No chest pain, palpitations, or edema

Skin: No rashes, lesions, or itching

Respiratory: No cough, shortness of breath, or wheezing

Eyes: No reported vision changes, denies eye pain.

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

Ears: No hearing loss, tinnitus, or ear pain

Genitourinary/Gynecological:

No urinary symptoms

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

Musculoskeletal: No joint pain, no falls.

Breast: Denies any change.

Neurological: No headaches, dizziness, or numbness

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

Psychiatric: Denies anxiety, or mood changes.

OBJECTIVE (Document PERTINENT systems only. Minimum 3)

Weight: 180lbs

Height: 5’9”

BMI: 25.9

BP:138/88mmHg

Temp: 99.2°F

Pulse: 78bpm

Resp:16/min

General Appearance: Well-nourished, alert, and oriented x3. Appears comfortable.

Skin: Smooth with no rashes, moles, red spots

HEENT: Normocephalic, PERRLA, oral mucosa pink and moist, no pharyngeal erythema or tonsillar enlargement.

Cardiovascular: Regular rhythm and rate. S1 and S2 present, no gallops or rubs were heard.

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