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Format for History and Physical Exam

Name: Mr. X Date of Birth: 05/05/1946Address: The bottom Age: 66

Sex: Male

Marital Status: married Race: Afro-CaribbeanName of Physician: Dr. KootSource of History: patient, and patients file, and Dr. KootDate of Evaluation: January 14, 2013

Chief Complaint: I have heartburn and diarrhea again.

History of Present Illness:

Patient has returned for a follow up from a previous appointment. The patientcomplains of constant heartburn as well as diarrhea. He is constantly bloated, and haspain in his abdomen. Pepto-Bismol has previously provided some relief of symptomsbut for the most part nothing else makes his heartburn or gas better. After meals it isworse, but the symptoms are present all the time. The patient has a past history of thesame chief complaint that goes back many years. He complains of diarrhea, gas, andbloating as well at the same time the heart burn comes about.

The patient has been previously treated for the heart burn and diarrhea. Hementions the heartburn and bloated feeling has been present for 20 years, and hasntreally changes since its started. He was previously taking nexium.The patient does not appear to be in acute distress presently, there is no difficultybreathing, no cough, no blood in stool, no complains of headache, no vomiting and nodifficulty urinating or with bowel movements.

Current medications: pepto- bismol

Habits: no illicit drugs, 4-5 alcoholic drinks/week

Allergies: no known allergies

Past History:


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Childhood illnesses: N/A

Adult illnesses: Previously had high blood pressure but is under control, has highcholesterol, and was positive recently for H. pylori on breath test and was treated

Surgical history: none

Accidents: not known

Hospitalizations: endoscopy was performed 3 months prior, and was normal

Immunization: (DPT, polio, MMR, flu, pneumococcal, hepatitis, etc, PPD, date of lastTd):

Screening Tests: Positive for H. pylori in October, 2012

Lifestyle: not much exercise, no smoking, a few drinks per week. Typical saba diet,has been eating less due to his heartburn and diarrhea.

Family History:

Family history was not discussed during this appointment since the patient has beenseen repeatedly. There was no information about family history in the patients file.The patient is currently married.

Social history:

Geographic: lives in the bottom, Saba.

Occupation: general labour.

Homelife: Married

Review of systems:


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General: no weight change relative to diet, he has been about the same or slightly lessand lost a couple of points since his last appointment 3 months prior.

Skin: no changes in skin, nails and no visible rashes on inspection

Head: currently no headache present. No neurological exam was performed

Ears: Hearing is normal

Eyes: no redness in the eyes, no jaundice, pupils were equal in size and symmetrical.

Nose: Did not complain of a change in smell, no discharge, no redness, no

inflammation, and no bleeding.

Mouth/throat: no sores, no bleeding, good hygiene visible. Gums were not swollenand were a pink colour.

Neck: No tenderness, no swollen lymphnodes, no neck stiffness.

Pulmonary: sometimes has a non productive cough with burning in the chest.

Cardiovascular: the patient previously had hypertension, his blood pressure today,and the last few check ups was is now 120/82, 126/84, 132/180. There are nocomplains of feeling his own heartbeat, no dizziness, and no shortness of breath.

GI: appetite is relatively normal, has been eating a little bit less but has a normal sabadiet, there is no dysphagia, there is a constant heartbur along with a vague abdominalpain sometimes after meals but sometimes eating makes the pain dissapear, complainsof flatulence, and has had a constant diarrhea for quiet a few years along with theheartburn.

GU/sexual: The patient did not mention any difficulty in urinating, no urgency orstraining, and no dribbling. There hasnt been a change in strength of urinary stream

either. There is no penile discharge or sores, no scrotal swelling.

Endocrine/metabolic: there has been no complains of change in hat size, no thyroidlumps or any lumps in the neck region, no complains of heat or cold intolerance.Fasting sugar levels were within normal limits.

Hematologic: no anemia or easy bruising


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Musculoskeletal: some leg cramps, but no complains of weakness, no change inROM.

Peripheral vascular: has previously mentioned leg cramps, no visible varicosities

Neurologic:no changes in mental capacity, no changes in memory, no changes inmotor or sensory function.

Psychiatric: the heartburn and diarrhea cause stress in his life, but otherwise thepatient is a happy and enjoys life.


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Physical examination

Vital signs: oral temp: 37 degrees Celsius, pulse: 78 bpm, 15 breaths/min, bloodpressure right arm: 120/80 while sitting, weight: 130 lbs, height: 56, BMI: 23)

General appearance: skinny male in no signs of distress, no use of accessorymuscles, sitting comfortably. Patient had good hygiene as well.

Skin, hair, nails: no visible rashes, scars, skin is normal pigmenent with no areas ofhypopigmentation or hyperpigmenetation. Nails were clean, and cut with no dimpling orpetechiae.

Head: small area of baldness, but otherwise no deformities

Eyes: conjunctiva and sclera were normal with no signs of tearing or jaundice ordiscoloration. Pupils were equal in size and shape and reactive to light, pupilsaccomdated. No problems with extra-ocular movements.

Ears: hearing was normal, with no discharge or excessive cerumen.

Nose: no discharge

Mouth/throat: no foul odour on breath, lips were read with no cuts or discoloration,buccal mucosa was normal, gums were pink and not swollen, teeth had no obvioussigns of trauma or infection, tongue was a red colour. Voice sounded normal withnormal character

Neck: no masses or nodules, normal ROM, no pain.

Lymph nodes: lymph nodes were non palpable and non tender.

Chest and Lungs: skinny chest with normal AP diameter, no use of accessorymuscles, no diffuclty breathing, no rapid chest movements, no tracheal deviation, no

cyanosis, or clubbing.


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Cardiovascular/Peripheral vascular full cardiovascular exam was not performedduring this visit

Abdomen normal contour of abdomen,no skin lesions, no abnormal venous patterns;bowel sounds were present with no bruits; tenderness on deep palpation of theabdomen that is not localized; liver and spleen were not checked

Rectal examcolonscopy taken a couple weeks prior to visitwas normal, nohemorrhoids, no diverticulitis, no fissures.

Male genitaliagenital exam was not performed

Musculoskeletal the patient was ambulatory but no musculoskeletal exam was

performed

Cranial nerves: optic and occulomotor nerves were checked on this visit and had noabnormalities. None of the other cranial nerves were examined.

Reflexes reflexes were not examined

Strength no strength testing done

Sensory exam no sensory exam performed

Cerebellar testing cereberallar testing was not performed

Assessment

1. Chronic gastritis. He has heartburn and diarrhea and vague abdominal pain. Hehas bloating and flatulence, and his heartburn was somewhat relieved bypeptobismol but it doesnt seem to provide as much relief anymore.

2. The gastritis could be due re-infection with H.pylori which would provide reasonfor the heartburn and diarrhea

3. A late onset celiac sprue could also cause heartburn, indigestion, diarrhea,flatulence and vague abdominal pain. If gluten was not removed from his dietand this was the cause it would explain why the symptoms have not gone away.

4. Peptic ulcer disease. His long standing heartburn as well as previous infectionswith H. pylori could have lead to the formation of an ulcer.


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PlansSmall bowel biopsy would provide insight into the condition of his bowel, could help indiagnosis of both the chronic gastritis as well as the celiac sprue. A stool antigen testshould be performed for infection and colonization by H. pylori followed by treatment if

necessary, as well as a urease breath test post treatment. Beginning treatment with aproton pump inhibitor would be useful and providing some relief to the patient. Itspossible that there is one type of food that is providing discomfort and identifying itcould be of use in providing relief. The patient could go on a diet where he removedone type of food at a time for at least a few days or a week to see if it provides relief.

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