Case Study: Abraham is a 58-year-old man who comes to the clinic complaining of heartburn that has been bothering him for the past 2 months. He describes the pain as a burning sensation in his chest that is worse when he lies down at night. He has tried over-the-counter antacids and histamine blockers, but they have not provided relief. He has also lost 5 pounds over the past 2 months. He denies any nausea, vomiting, dysphagia, or hematemesis. His stools are normal. He has no significant medical history and takes no medications other than over-the-counter antacids and histamine blockers. He has never smoked and drinks alcohol only on occasion. He works as a construction worker

Problem Statement

Primary Diagnosis with ICD-10 code, rationale and resources. Include CPT codes, and any procedural codes, including nurse lab draws, vaccinations given, biopsies, etc.

Guidelines used to develop this primary diagnosis. 5 pts

Differential diagnoses with rationale and resources. 3-5 Ddx required, unless well visit.

ORDER A CUSTOMIZED, PLAGIARISM-FREE Case Study: Abraham is a 58-year-old man who comes to the clinic complaining of heartburn that has been bothering him for the past 2 months. He describes the pain as a burning sensation in his chest that is worse when he lies down at night. He has tried over-the-counter antacids and histamine blockers, but they have not provided relief. He has also lost 5 pounds over the past 2 months. He denies any nausea, vomiting, dysphagia, or hematemesis. His stools are normal. He has no significant medical history and takes no medications other than over-the-counter antacids and histamine blockers. He has never smoked and drinks alcohol only on occasion. He works as a construction worker HERE

Medications including OTC, dosage and education

Additional ancillary tests needed

Referrals and follow up

Social Determinants of Health to consider,

Health Promotion and Pt risk factors

Must use three scholarly references

Patient Information:

Case Study #1 Abraham- GERD

Patient History

Abraham is a 58-year-old man who comes to the clinic complaining of heartburn that has been bothering him for the past 2 months. He describes the pain as a burning sensation in his chest that is worse when he lies down at night. He has tried over-the-counter antacids and histamine blockers, but they have not provided relief. He has also lost 5 pounds over the past 2 months. He denies any nausea, vomiting, dysphagia, or hematemesis. His stools are normal. He has no significant medical history and takes no medications other than over-the-counter antacids and histamine blockers. He has never smoked and drinks alcohol only on occasion. He works as a construction worker.

Physical Exam

Abraham is a well-nourished man in no apparent distress. His vital signs are all within normal limits. His abdominal exam is benign with no tenderness, guarding, or masses. His cardiac exam reveals regular rate and rhythm with no murmur, rub, or gallop. His lungs are clear to auscultation bilaterally.

Assessment

Abraham is a 58-year-old man with a 2-month history of heartburn. He has tried over-the-counter antacids and histamine blockers, but they have not provided relief. He has also lost 5 pounds over the past 2 months.

His physical exam is unremarkable except for mild tenderness to palpation in the epigastric region. His cardiac exam is also within normal limits.

Based on the information provided, Abraham’s most likely diagnosis is gastroesophageal reflux disease (GERD).

Laboratory Studies

Abraham’s laboratory studies are all within normal limits.

Imaging Studies

Abraham’s imaging studies are all within normal limits.

Treatment

The treatment for Abraham’s GERD will include a proton pump inhibitor (PPI) such as omeprazole (Prilosec). He will also be advised to avoid trigger foods and beverages such as caffeine, chocolate, fatty foods, spicy foods, and citrus fruits. He will be advised to lose weight if he is overweight and to avoid lying down within 3 hours of eating. He will also be advised to sleep with his head elevated. If his symptoms do not improve with these measures, he may require a referral to a gastroenterologist for further testing and treatment.

Referral

If Abraham’s symptoms do not improve with medical management, he may require a referral to a gastroenterologist for further testing and treatment.

Follow-Up

Abraham will follow up with his primary care provider in 1 month.

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