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Penny GarnerSeptember 3, 2013GNRS 5668SOAP #1SUBJECTIVE Demographic Data: 40 y/o Caucasian female presents to clinic as an established patient although she has not been seen since 12/2011. States she lives in a trailer park in Orange with her spouse and their 11 y/o daughter. Patient and spouse both smoke in the home and both drink alcohol on a daily basis. Patient works F/T at Wal-Mart.Chief Complaint: abd pain w/ burning esophagus unimproved since last OV on 8/27/13History of Present Illness: Patient was seen on 8/27/13 for c/o vomiting x 4 days, sore throat, excess drooling, and stomach cramps. Patient reported her mouth burned like it was blistered. She was diagnosed with pharyngitis and non-specific abd pain. Her physical assessment is not available for review from this visit. She was given Lincocin 2ml with Decadron 1ml IM in clinic. She was prescribed Bactrim DS 1 PO BID #20 and Zofran ODT 4mg Q8hrs PRN-n/v #20. She was ordered to do a CBC, CMP, amylase, and lipase. She was given “ER warnings” and to take clear liquid diet as tolerated. Her recommended F/U is not written in the chart. VS: BP 120/80, Temp 98.1, Weight 107#, BMI 20 (no heart rate or respirations available) AOS: Onset- about 2 wks agoDuration- “all day”Frequency- every dayLocation- mid upper epigastric, to RUQ and LUQ at times Setting- all settingsQuality- burning, stabbing, crampingQuantity- 9-10/10 scale of intensity Associated Symptoms- n/v, burning esophagusAggravating Factors- any foods or fluidsAlleviating Factors- noneCurrent Health Status:Allergies: NKDAMedications: Bactrim DS 1 PO BID #20 (given on 8/27/13) Zofran ODT 4mg Q8hrs PRN-n/v Ibuprofen PRNImmunization Status: UTD including Td in 2011Habits: Smokes 1-1.5 PPD; drinks 6 pack beer/day; smokes marijuana “every once in a while”; denies illicit drug useLast PE/Pap/Mammo: PE and PAP on 12/20/11 and was nml; manual breast exam same visit was nml. Mammo not indicated. Nutrition: for the past 2 wks nutritional intake has been minimal due to abd pain, esophagitis, and poor appetite. States has only eaten bland soups and any liquids that don’t burn her throat. Reports poor fluid intake also.Exercise: Denies any exercise at all. Relative Past Medical History: General: reports not usually sick except for seasonal allergiesSurgeries: C-section 2000Blood Transfusions: deniesHospitalizations: deniesSerious Accidents/ Injuries: deniesMajor Illnesses:Childhood: Tourette’s syndrome Adult: Tourette’s syndromeImpact on Lifestyle: Has missed 2 days of work and unable to eat. Social History:Home Living: Lives in trailer w/ spouse and daughter. Has no pets. Smoking and alcohol consumption in home on a daily basis. Occupation: Clerk at Wal-Mart F/TEconomic Resources: Her and spouse both work F/T. Denies any economic difficulties. Religious Considerations: was raised Baptist but doesn’t routinely practice any specific religionFamily History: Non-contributory to chief complaint today. Patient’s Explanatory Model: “I’m wondering if it’s my gallbladder causing all this abdominal pain.”Review of Systems:General – denies change in lifestyle prior to this episode of abd pain; denies chills, night sweats, lethargy; confirms malaise, fatigue at times Skin – denies rashes, bruising, mole changes; denies any changes in hair or nails; confirms some pruritis to arms and legs for a few daysThroat– confirms oral pain, sore throat; denies gum bleeding/swelling, vocal changes, tooth lossCV – denies c/p, dizziness, orthopnea, edema, palpitations, weakness; also denies numbness, tinglingChest and lungs – denies cough, dyspnea, SOBGI – confirms abd pain to mid upper epigastric worsening over last 2 wks and worsens after consuming a meal, describes pain to RUQ and LUQ intermittently; nausea and cramping x 2 wks w/ vomiting 1 wk ago. Denies vomiting this last week. Denies change in bowel habits or diarrhea/constipation. Last BM yesterday was nml. Denies dysphagia, heartburn, or hematochezia. Confirms painful swallowing. Female GU – denies burning or painful urination, hematuria, incontinenceLymph – denies painful or swollen lymph nodesOBJECTIVEPhysical exam:General – appears older than stated age, thin, poor grooming and smells of cigarette smoke, well-mannered; posture is slightly bent forward and carrying a container for her sputum (excess drooling); speech is nml, noted Tourette tremors to head and neck; no signs of acute distressVital Signs – BP 108/62, HR 69, Pulse Ox 97% on R/A, Temp 98.2 Height 5’2”, Weight 109#, BMI 20Skin – pale and dry, skin turgor fair; no cyanosis or clubbing; cap refill < 3 sec; slightly jaundiceThroat- inspection reveals unable to open mouth very wide due to painful burning, no lesions/ulcers/exudates noted but entire mouth is extremely excoriated including buccal mucosa, hard and soft palate; tongue is midline, hyper gag reflex noted; uvula and tonsils present and erythematousCV – RRR, no murmur, no edemaChest and lungs – lungs are clear throughout; chest symmetrical, no accessory muscle use; no signs of resp distress notedGI – abd with normal contour, soft w/ normoactive bowel sounds x 4 quads; percussion nml w/ no rigidity; palpation reveals slight tenderness to bilat upper quads, no guarding, no rebound tenderness, no hepatosplenomegaly; no CVA tenderness; neg for Rovsing’s, McBurney’s, Psoas, Murphy’s, Obturator signsLymph – no lymphadenopathyDiagnostic/Lab Data: patient did not get the labs done that were ordered on 8/27/13ASSESSMENTMedical Diagnosis: Abdominal pain (789.0): This is confirmed symptomology patient is subjectively reporting. No definitive diagnosis has been reached as patient did not get labs done from last week that were ordered. She has not improved despite conservative treatment last week. She has not worsened. Esophagitis (530.12): Commonly associated w/ GERD. Predisposing factors include ingesting substances that promote lower esophageal sphincter (LES) relaxation. Examples would be obesity, emotional stress, consuming large meals, alcohol, and smoking. Some alarm symptoms include unintentional weight loss, upper abdominal pain, hematemesis, melena, and painful swallowing. Other s/s include retrosternal aching or burning, water or “acid” brash, hoarseness, nausea, and dental erosion. (Glass, 2011).Pertinent Positives: daily alcohol consumption, smoking, upper abd pain, painful swallowing, “acid” brash; physical exam reveals an extremely excoriated mouth.Pertinent Negatives: patient is thin and reports portion control on meal sizes. She has actually gained 2# in the last week and denies hematemesis, melena, and retrosternal burning. Differential Diagnosis:1. Pancreatitis (577.06) – pending lab results. Location and duration of abd pain can help in narrowing the DD. Acute pancreatitis is associated with RUQ and LUQ abd pain that is relatively sudden and radiates to the back. It is associated w/ n/v and anorexia. (Glass, 2011).2. Cholycystitis (575.10) – pending lab results. Location and duration of abd pain can help in narrowing the DD. RUQ abd pain can be significant for acute cholecystitis. This pain radiates to the scapular region and is accompanied by n/v, and fever without jaundice. Murphy’s sign may be positive. RUQ tenderness to percussion or pressure of the gallbladder is also suggestive of this diagnosis. (Glass, 2011). PLANPharmacotherapeutics: continue Bactrim until complete; continue use of Zofran PRN-nausea/vomiting; new-Dexilant 60mg 1 tab daily #28 (samples given)Diagnostic tests: CBC, CMP, amylase/ lipase TODAYConsults/Referrals: refer to GastroenterologistPatient education: continue clear, bland liquid diet as tolerated; instructions on new med Dexilant as a PPI; importance of F/U with Gastro since this issue has not improved or resolvedFollow-up care: 1 week unless able to see Gastro by then or ER if worsensAddendum9/4/13: Lab results are obtained. The following are abnormals and their significance:BUN/ Creatinine elevated – suggesting renal insufficiency at this time. Could progress to renal failure if left untreated. Total Bilirubin elevated – liver disease such as hepatitis or cirrhosisAST/ALT elevated – liver disease, alcohol abuse Amylase/lipase elevated – acute pancreatitis, acute cholecystitis, acute alcohol ingestionWBC elevated – infectionAbsolute Neutrophils elevated – acute bacterial infection, inflammationAbsolute Mono’s elevated – chronic infectionAbsolute Eosinophils elevated – inflammationPatient is called to go to the ER for further evaluation of her pancreas, liver, and gallbladder. The lab results are faxed to the Medical Center’s ER and report called to the triage nurse in anticipation of the patient’s arrival soon. ReferencesGlass, C.A. (2011). Gastrointestinal Guidelines. In J.C. Cash & C.A. Glass (Eds.), Family Practice Guidelines (p. 202). New York, NY: Springer Publishing Company. Article SummaryAccording to Parry, Patra, & Rehm’s article Alcohol Consumption and Non-Communicable Diseases: Epidemiology and Policy Implications (2011), alcohol has been identified as a leading risk factor for death and disability accounting for 3.8% of deaths and 4.6% of disability in 2004. Alcohol was found to be the 8th highest risk factor for death and the 3rd highest for disability in the same year (Parry, Patra, & Rehm, 2011). Alcohol is also linked to eight different cancers as well as cardiovascular disease, pancreatitis, and liver disease (fatty liver, alcoholic hepatitis, and cirrhosis), with the risk increasing with the volume consumed. Cirrhosis is the most common disease found and is associated with a risk of 7.7% of death among women (Parry, Patra, & Rehm, 2011). The view on the mechanism of action for liver disease associated with alcohol consumption is the breakdown of alcohol in the liver leads to the generation of free radicals which damage liver cells. The article concluded that there is a strong link between alcohol and non-communicable diseases, particularly cancer, cardiovascular disease, liver disease, and pancreatitis. Alcohol was mentioned along with tobacco, diet and lack of exercise, as one of four major common risk factors for non-communicable disease in the recent status report of the World Health Organization. These findings support calls by the World Health Organization to implement evidence-based strategies to reduce harmful use of alcohol.Parry, C. D., Patra, J., & Rehm, J. (2011). Alcohol consumption and non-communicable diseases: epidemiology and policy implications. Addiction, 106(10), 1718-1724. doi:10.1111/j.1360-0443.2011.03605.x ................
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