Format for History and Physical Exam

Name: Mr. X Address: The bottom Date of Birth: 05/05/1946 Age: 66 Sex: Male Race: Afro-Caribbean

Marital Status: married Name of Physician: Dr. Koot Source of History: patient, and patients file, and Dr. Koot Date 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 patient complains of constant heartburn as well as diarrhea. He is constantly bloated, and has pain in his abdomen. Pepto-Bismol has previously provided some relief of symptoms but for the most part nothing else makes his heartburn or gas better. After meals it is worse, but the symptoms are present all the time. The patient has a past history of the same chief complaint that goes back many years. He complains of diarrhea, gas, and bloating as well at the same time the heart burn comes about. The patient has been previously treated for the heart burn and diarrhea. He mentions the heartburn and bloated feeling has been present for 20 years, and hasnt really changes since its started. He was previously taking nexium. The patient does not appear to be in acute distress presently, there is no difficulty breathing, no cough, no blood in stool, no complains of headache, no vomiting and no difficulty urinating or with bowel movements. Current medications: pepto- bismol Habits: no illicit drugs, 4-5 alcoholic drinks/week Allergies: no known allergies

Past History:

Childhood illnesses: N/A Adult illnesses: Previously had high blood pressure but is under control, has high cholesterol, 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 last Td): 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 been seen 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:

General: no weight change relative to diet, he has been about the same or slightly less and 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 swollen and 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 no complains 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 saba diet, there is no dysphagia, there is a constant heartbur along with a vague abdominal pain sometimes after meals but sometimes eating makes the pain dissapear, complains of flatulence, and has had a constant diarrhea for quiet a few years along with the heartburn. GU/sexual: The patient did not mention any difficulty in urinating, no urgency or straining, 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 thyroid lumps 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

Musculoskeletal: some leg cramps, but no complains of weakness, no change in ROM. Peripheral vascular: has previously mentioned leg cramps, no visible varicosities Neurologic: no changes in mental capacity, no changes in memory, no changes in motor or sensory function. Psychiatric: the heartburn and diarrhea cause stress in his life, but otherwise the patient is a happy and enjoys life.

Physical examination
Vital signs: oral temp: 37 degrees Celsius, pulse: 78 bpm, 15 breaths/min, blood pressure 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 accessory muscles, sitting comfortably. Patient had good hygiene as well. Skin, hair, nails: no visible rashes, scars, skin is normal pigmenent with no areas of hypopigmentation or hyperpigmenetation. Nails were clean, and cut with no dimpling or petechiae. Head: small area of baldness, but otherwise no deformities Eyes: conjunctiva and sclera were normal with no signs of tearing or jaundice or discoloration. Pupils were equal in size and shape and reactive to light, pupils accomdated. 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 obvious signs of trauma or infection, tongue was a red colour. Voice sounded normal with normal 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 accessory muscles, no diffuclty breathing, no rapid chest movements, no tracheal deviation, no cyanosis, or clubbing.

Cardiovascular/Peripheral vascular full cardiovascular exam was not performed during 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 the abdomen that is not localized; liver and spleen were not checked Rectal exam colonscopy taken a couple weeks prior to visitwas normal, no hemorrhoids, no diverticulitis, no fissures. Male genitalia genital 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 no abnormalities. 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. He has bloating and flatulence, and his heartburn was somewhat relieved by peptobismol but it doesnt seem to provide as much relief anymore. 2. The gastritis could be due re-infection with H.pylori which would provide reason for 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 diet and 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 infections with H. pylori could have lead to the formation of an ulcer.

Plans

Small bowel biopsy would provide insight into the condition of his bowel, could help in diagnosis of both the chronic gastritis as well as the celiac sprue. A stool antigen test should 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 a proton pump inhibitor would be useful and providing some relief to the patient. Its possible that there is one type of food that is providing discomfort and identifying it could be of use in providing relief. The patient could go on a diet where he removed one type of food at a time for at least a few days or a week to see if it provides relief.