lOMoAR cPSD| 16310474
I HUMAN WK #7 MR. JACOB
ABRAHAM IS A 58Y-O
CAUCASIAN MALE WITH A
HISTORY OF HTN,
BORDERLINE OBESITY, AND
BORDERLINE
HYPERLIPIDEMIA GERD, GI,
ACID REFLUX 2025
UPDATED
, lOMoAR cPSD| 16310474
Mr. Jacob Abraham is a 58yo Caucasian Male with a history of HTN, borderline obesity, and borderline
hyperlipidemia presents for burning chest discomfort. He reports episodic 4 to 5 out of 10 mid-sternal
chest burning that radiates to his neck (Adam’s apple). Episodes occur abruptly without precipita 琀椀
ng factors and slowly self-resolve over the course of 30 minutes. He reports 4 episodes over a one-week
span and awaken him from sleep. His current discomfort severity level is 1-2 out of 10. His discomfort is
improved with ea 琀椀 ng meals and walking around. He denies known aggrava 琀椀 ng factors, and he
has not a 琀琀 empted other home therapies for symptom control. He denies pain upon exer 琀椀 on,
recent chest trauma or injury, history of angina, or a history of GERD. Denies SOB, orthopnea, palpita 琀
椀 ons, dizziness, fa 琀椀 gue, dysphagia, n/v/d, or abd pain. He reports his diet consists of co 昀昀 ee
twice daily, fast food, sweets, and one healthy home cooked meal per day. He denies regular exercise.
He reports ETOH use of 1 drink of wine or whiskey 3-4 nights/wk. He denies concerns for alcohol
dependence. He denies tobacco use or NSAID use.
ROS
General:
Nega 琀椀 ve for fa 琀椀 gue, di 昀케 culty sleeping, uninten 琀椀 onal weight loss or gain, fever, or
night sweats
Card:
Posi 琀椀 ve for burning chest discomfort. EKG: never completed
Nega 琀椀 ve for dizziness, palpita 琀椀 ons, exercise intolerance, cyanosis, peripheral edema,
orthopnea, or dyspnea.
Resp:
Nega 琀椀 ve for dyspnea, cough, hemoptysis, SOB, or wheezing.
GI:
Posi 琀椀 ve for burning chest discomfort radia 琀椀 ng to neck, improved with ea 琀椀 ng meals.
Nega 琀椀 ve for N/V/D, cons 琀椀 pa 琀椀 on, abd pain, changes in bowel pa 琀琀 erns, melena,
hematochezia, or hematemesis
PE
Mr. Jacob Abraham is a 58yo Caucasian M presen 琀椀 ng for 1 week history of episodic burning chest
discomfort. He is si 琀 ng in a posi 琀椀 on of comfort, appropriately dressed, AAOx4, calm, coopera 琀
椀 ve with an appropriate a 昀昀 ect. NAD. He is a reliable historian.
I HUMAN WK #7 MR. JACOB
ABRAHAM IS A 58Y-O
CAUCASIAN MALE WITH A
HISTORY OF HTN,
BORDERLINE OBESITY, AND
BORDERLINE
HYPERLIPIDEMIA GERD, GI,
ACID REFLUX 2025
UPDATED
, lOMoAR cPSD| 16310474
Mr. Jacob Abraham is a 58yo Caucasian Male with a history of HTN, borderline obesity, and borderline
hyperlipidemia presents for burning chest discomfort. He reports episodic 4 to 5 out of 10 mid-sternal
chest burning that radiates to his neck (Adam’s apple). Episodes occur abruptly without precipita 琀椀
ng factors and slowly self-resolve over the course of 30 minutes. He reports 4 episodes over a one-week
span and awaken him from sleep. His current discomfort severity level is 1-2 out of 10. His discomfort is
improved with ea 琀椀 ng meals and walking around. He denies known aggrava 琀椀 ng factors, and he
has not a 琀琀 empted other home therapies for symptom control. He denies pain upon exer 琀椀 on,
recent chest trauma or injury, history of angina, or a history of GERD. Denies SOB, orthopnea, palpita 琀
椀 ons, dizziness, fa 琀椀 gue, dysphagia, n/v/d, or abd pain. He reports his diet consists of co 昀昀 ee
twice daily, fast food, sweets, and one healthy home cooked meal per day. He denies regular exercise.
He reports ETOH use of 1 drink of wine or whiskey 3-4 nights/wk. He denies concerns for alcohol
dependence. He denies tobacco use or NSAID use.
ROS
General:
Nega 琀椀 ve for fa 琀椀 gue, di 昀케 culty sleeping, uninten 琀椀 onal weight loss or gain, fever, or
night sweats
Card:
Posi 琀椀 ve for burning chest discomfort. EKG: never completed
Nega 琀椀 ve for dizziness, palpita 琀椀 ons, exercise intolerance, cyanosis, peripheral edema,
orthopnea, or dyspnea.
Resp:
Nega 琀椀 ve for dyspnea, cough, hemoptysis, SOB, or wheezing.
GI:
Posi 琀椀 ve for burning chest discomfort radia 琀椀 ng to neck, improved with ea 琀椀 ng meals.
Nega 琀椀 ve for N/V/D, cons 琀椀 pa 琀椀 on, abd pain, changes in bowel pa 琀琀 erns, melena,
hematochezia, or hematemesis
PE
Mr. Jacob Abraham is a 58yo Caucasian M presen 琀椀 ng for 1 week history of episodic burning chest
discomfort. He is si 琀 ng in a posi 琀椀 on of comfort, appropriately dressed, AAOx4, calm, coopera 琀
椀 ve with an appropriate a 昀昀 ect. NAD. He is a reliable historian.
