Chief Complaint: “Burning discomfort in stomach ” x 3 months

History of Present Illness:

49 y/o male with a past medical history of HTN and diabetes that comes in today with a burning sensation in his stomach for 3 months. Patient reports that the symptoms are localized towards his RUQ and do not radiate anywhere. Patient states that the symptoms are intermittent and episodes usually last about 10 minutes.Patients state that the burning sensation occurs after he eats meals and resolves if he drinks a cold glass of milk.Patient states the symptoms cause him more discomfort than pain but states the discomfort is 5/10 when it arises. Patient denies taking any medications to help relieve the pain and states only the cold milk seems to help. Patient denies any regurgitation, pyrexia, cough,  pleuritic pain, diarrhea, constipation, N/V.

Past Medical History:

• Diabetes x 3 years
• HTN x 10 years 

Past Surgical History:

• No past surgical history

Medications:

• Metformin 1000 mg orally twice a day 
• Amlodipine 10 mg once daily 

Allergies:

• No known drug allergies
• No known food allergies
• No known environmental allergies

Family History:

• Mother: deceased, MI at age 71
• Father: Age 72, alive with pmh of HTN, Alzheimer’s disease
• Siblings: 2 sisters, 1 brother 
• Children: 2 daughters, healthy 

Review of Systems:

• General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss or gain, changes in appetite.
• Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.
• Head: Denies head trauma, vertigo.
• Eyes: Denies ear pain, deafness, discharge, tinnitus.
• Ears: Denies deafness, ear pain, discharge, tinnitus.
• Nose: Denies epistaxis, discharge, congestion
• Mouth/throat: Denies sore throat, voice changes, bleeding gums.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Breast: Denies lumps, nipple discharge, pain.
• Pulmonary: Denies cough, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, cyanosis, hemoptysis.
• Cardiovascular: Denies chest pain ,edema/swelling of ankles or feet, hx of HTN, palpitations, irregular heartbeat, syncope, known heart murmur.
• Gastrointestinal: Admits to burning sensation in RUQ. Denies change in appetite, intolerance to specific foods, abdominal pain nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
• Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
• Sexual History: Admits to currently being sexually active with 1 female partner. Admits to condom use. Denies history of STIs.
• Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
• Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Denies intermittent claudication, varicose veins, coldness or trophic changes, color changes, peripheral edema.
• Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
• Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
• Psychiatric: Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

Physical Exam: 

Vitals:

• BP: 127/86(seated,left arm)  Right 131/84(seated, right arm)
• HR: 78 BPM (regular)
• RR: 16/min (unlabored)
• T: 98.1 F (oral)
• O2: 98% (room air)
• Height: 71 in Weight: 200lbs BMI: 26.4

General: AAO x 3, appears in no acute distress, well groomed, appears stated age

Skin: Warm & moist; good turgor; non-icteric; no rashes or lesions noted

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink.

Ears: Symmetrical and appropriate in size. No lesions, masses or trauma on external ears. No discharge or foreign bodies on external auditory canals.TM pearly grey and intact with light reflect in good position 

Nose: Symmetrical. No masses, lesions, deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated

Sinus: Non-tender to palpation.

Mouth/pharynx: Mucosa pink and well hydrated. Pharynx non-erythematous. No exudates or lesions visualized. Uvula midline.

Neck: Trachea midline. Supple and nontender to palpation. No cervical adenopathy noted.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur.

Chest: Symmetrical, no deformities. Respirations unlabored, no accessory muscle use.

Lungs: Clear to auscultation bilaterally.

Abdomen: Mild tenderness over RUQ. Abdomen round and symmetric, no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Tympanic throughout, no guarding or rebound noted. Negative CVA tenderness.

Nervous system: Cranial nerves I-XII intact.

Peripheral vascular: Pulses 2+ bilaterally in upper and lower extremities. No clubbing, cyanosis or edema noted.

Musculoskeletal: FROM (full range of motion) of all upper and lower extremities bilaterally. Non tender to palpation.

Rectal: exam not performed. 

Differential Diagnosis:

Choleliathiais-Clinical manifestation for patients with gallstones present as episodic RUQ pain that is precipitated by fatty foods or large meals. My patient presents with a RUQ burning sensation that lasts about 10 minutes, and has certain risk factors that increase that chances of this diagnosis like being overweight and in his forties. On physical exam my patient was also tender over this RUQ region making this diagnosis most likely. 

GERD: Patient states that he has this burning sensation in his abdomen after food intake.Noting the patient’s body habitus and descriptions of symptoms, GERD is a diagnosis that comes to mind. But based on PE, in which the patient had mild RUQ tenderness and lack of  symptoms such as regurgitation, heartburn  or a cough this diagnosis is less likely.

Peptic Ulcer disease: Peptic ulcers(specifically gastric ulcers)is characterized as gnawing epigastric pain that is exacerbated by food intake.  My patients chief complaint may include this ddx as abdominal discomfort is seen in patients with PUD. But the lack of other associated symptoms such as nausea/vomiting, weight loss this diagnosis is less likely. My patient also did not state excessive use of NSAIDS which the most common cause of gastric ulcers. 

Assessment: 49 y/o male with medical history of HTN, Diabetes comes in today with burning sensation in his stomach for 3 months. Patient states that the pain is associated after eating a meal and is relieved with a cold glass of milk. Upon examination, the patient had slight tenderness in the RUQ with palpation, no rebound tenderness or guarding was noted. At this point, we will send him for an abdominal ultrasound to look for the underlying cause.

Plan:

Cholelathiais 

1. Referral: Abdominal Ultrasound(Note: patient has been experiencing postprandial RUQ discomfort/burning for 3 months.)
2. Dietary changes(Avoid fatty foods)
3. Follow up appointment after Ultrasonography 
4.  Referral to Gastroenterologist(Note: Abdominal discomfort x 3 months; Colon cancer screening)