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Ihuman Jacob Abraham 58y/o Reason for encounter: Burning chest di

Questions
1. HowcanIhelpyoutoday
a. “Ivebeenhavingsomechestdiscomfort.”
2. Doyouhaveanyothersymptomsorconcernsweshoulddiscuss?
3. Whendidthepaininyourcheststart
4. Isyourchestpainprecipitatedbyexercise
5. Doesanythingmakethepaininyourchestbeterorworse
6. Wheremorepreciselyisthepaininyourchest
7. Howsevere(1-10)isthepaininyourchest a. 4-5/10
8. Doesthepaininyourchestradiatesomeplaceelse?
a. Movesupintoneck(pointingtoadamsapple)
9. Haveyouhadthepaininyourchestbefore? 10.Anychangeinyourchestpainsinceitbegan 11.Howlongdoesyourchestpainlast
a. Last30minutes 12.Howoftendoesthischestpainocur
13. Doyoudrinkalcohol?Ifsowhatdoyoudrinkandhowmanydrinksperday?
a. 1drinkpostdinner,notQnight.
14. Canyoutellmeaboutyourdiet?Whatdoyounormallyeat?
15. Doyouhaveanyproblemswithfatigue,difficultysleeping,unintentionalweightlossorgain 16.Doyouexperienceshortnessofbreath,wheezing,difficultycatchingyourbreath
17.Doyouhaveproblemswithnauseavomitingconstipationdiarrheacoffeegroundsinyourvomit 18.Hasdrinkingalcoholevercauseyouproblems?
19. Haveyoueverfeltyouneededtocutdownonyourdrinking?
20. Haveyoueverbeenannoyedatanyoneforsuggestingthatyoucutbackinyouralcoholconsumption? 21.Doyouneedanalcoholicdrinkfirsthinginthemorning?
22. Whenandwhatdidyoulastdrink?
23. Doyoupresentlyhaveheartburn,afoodoracidtasteinyourmouth? 24.Doyouhaveahistoryofheartburn?
25.Doyouhaveanyproblemswithnervousness,depression,lackofinterest,sadness… 26.Doyouhavedifficultybreathing
27.Hasanyonesuggestedthatyoushouldreducetheamountofalcoholyoudrink
:::MISSING
in PMH 1
in Etiology 1

Diagnosis: GERD
:Differential diagnosis
:Madalyn put
Unstable angina -
GERD -
Pneumonia -
Aortic dissection -
Acute coronary syndrome -
Sprain/strain -
Gastritis -

Peptic ulcer disease - Dyspepsia, functional -
:I put
- GERD
- Peptic ulcer disease
- Achalasia
- Gastritis
- Dyspepsia
- Gastroparesis Coronary artery disease -
Hiatal hernia -
Pancreatitis, chronic -

:Findings
Poor eating habits -
Alcohol use - Obesity -
Burning chest pain radiating into the neck -
Lack of exercise -

correct, found-

correct, found-

.P.E
BP: 130/ 84, laying Pulse: 88
RR: 16

correct, found-

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Specificaties

Niveau: University
School: Chamberlain College Of Nursing
Opleiding: NURSING
Studiejaar: 2023/2024
Document
Rubriek: Tentamens
Gemaakt op: 10-10-2023
Type: .pdf
Pagina's: 14
Taal: English
Tags
Ihuman Jacob Abraham 58y/o Reason for encounter: Burning chest di

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