RESPONSE 1:
#1, 50-year-old female, bitter taste in mouth
SUBJECTIVE
Biographical Data: 50-year-old female
Source: self
CC: complains of being wakened up at night with a bitter taste in her mouth about four times per week for the past two months
HPI/ROS: Patient (name) is a 50-year-old female who complains of being awakened 4x/week with a bitter taste in her mouth for the past 2 weeks. She states it is interfering with her sleep, and she is concerned. Other questions of interest would include:
Has this ever happened before? If yes, when, what was the diagnosis, and how was it treated? Did the treatment work until now?
Does it happen during the day?
Is it intermittent or continuous? How long do the episodes last?
What helps it? What makes it worse? Have you taken any medications for it?
Can you distinguish other tastes? Sour? Sweet? Salty? Metallic? Do you have loss of taste?
Did you start any new medications recently?
Any dental problems? Pain? Cavities? Dental work? Sores or abscesses in mouth, gums, throat? Any recent nasal congestion or URI symptoms?
Any difficulty smelling?
Heartburn or reflux?
Any weight loss? Fatigue? Fever?
PMH:
History of a precipitating event?
Recent trauma?
Recent medical procedure?
Cancer therapy (chemo or radiation)?
Do you have any endocrine or neurological disorders?
When is the last time you have seen a dentist?
Allergies: Ask about allergies to medications, foods, latex, pets, environment and what happens when exposed?
Medications: Ask what medications she is currently taking? Prescription? OTC? Herbal? Supplements? Vitamins?
Family History: Ask about family history of mother, father, maternal and paternal grandparents, siblings, health status, diagnosis, age at death, cause?
Personal and Social Hx:
Do you drink alcohol? How often? How much?
Do you use illicit drugs? If historical, last time using?
Do you smoke cigarettes? How many packs/day, for how long? Vape? Marijuana (ask because these days people don’t always categorize THC as an “illicit drug”)?
What is your diet like? The last 3 days give specifics.
Have you traveled? When/where?
OBJECTIVE
General – (VS, Ht, Wt, BMI, appearance, apparent distress, cooperative, alert/oriented, obese, dress)
Skin – (warm, dry, turgor, soft, rashes, lesions, masses, pigmentation/discoloration, nodules, lacs, ulcerations, nail changes, normal/abnormal hair distribution, hair loss)
HEENT – Assess: Face/sinus tenderness, oral cavity/mucosa for sores, discolorations, lesions; gums and teeth for decay, gingival, or periodontal inflammation, bleeding; quantity and consistency of saliva, missing teeth? Post nasal drip? Parotid and Submandibular swelling? Ears for OM, drainage? Dry eyes?
Neck: swollen cervical glands? Thyroid swelling, nodules?
Respiratory: Breath sounds in all fields
Cardiac: Rate, rhythm, cardiac sounds
Neurological: Cognitive and cranial nerve function?
Diagnostic: labs, xrays, other clinicians, old findings
ASSESSMENT
(www.icd10data.com)
1. working diagnosis – Unspecified disturbance of smell and taste, R43.9
Pertinent positives: bitter taste in mouth x2 months (phantogeusia – Phantogeusia is a non-triggered, intermittent, or permanent taste distortion which includes complaints such as metallic, bitter, sour, salty, and sweet tastes (Bhanot & Sharma, 2017).
2. differential diagnosis – Periodontal disease, K05.6
Pertinent positives: bitter taste in mouth, loose teeth (?), dental abscess (?), necrotizing gingivitis (?) (Bhanot & Sharma, 2017)
Pertinent negatives: no halitosis (?), no inflamed gingiva (?), no loose teeth (?), no decay (?) (Bhanot & Sharma, 2017)
3. differential diagnosis – Upper respiratory infection, J06.9
Pertinent positives: Taste disturbance, respiratory (or post-respiratory) infection (?) (Bhanot & Sharma, 2017)
Pertinent negatives: no congestion (?), no hx of URI (Bhanot & Sharma, 2017)
PLAN
1. New tests or orders:
Taste threshold test – Using taste test strips is the most efficient way to test taste thresholds. This is the most commonly used, credible test for dysgeusia. Four categories of taste are tested including sweet, sour, salty, and bitter. (Jafari et al., 2021)
Taste quadrant test – This test can measure specific areas of the tongue and oral cavity, rather than just the overall qualitative results. It measures four quadrants of the tongue and two sides of the soft palate. (Jafari et al., 2021)
CBC
B12
Iron
Zinc
Calcium
Potassium
HgbA1c
BUN
Thyroid studies
(Bhanot & Sharma, 2017) (Jafari et al., 2021)
2. Do you need referral to a specialist? Pending labs/diagnosis
3. What discharge instruction/education will you give the patient?
Use non-metallic silverware
Avoid metallic or bitter-tasting foods
Increase protein intake
Flavor foods with spices and seasonings
Serve cold food to reduce unpleasant taste or odor
Brush teeth often
Use mouthwash
Use sialogogues such as sugar-free gum or sour-tasting drops that stimulate the taste buds
Reassurance
(Jafari et al., 2021)
4. How soon should the patient come back for follow up? RTC in 2 weeks to discuss lab results.
5. Medications – None
RESPONSE 2:
Choice #2 – 48-year old male GI symptoms
SUBJECTIVE
CC – “My stomach hurts and I’m nauseated for about 3 weeks, especially after eating”.
HPI: 48 yo male seen today for epigastric pain that is worse after eating x 3 weeks. Symptoms are accompanied by nausea but patient denies vomiting or diarrhea at this time. Reports stools as “normal” in color and consistency.
– How would you describe the pain?
– How bad is the pain on a scale from 0 to 10?
– Have you taken any medications to help with the pain?
– Other than eating, are there any other aggravating factors?
– Do you regularly take over the counter pain killers such as ibuprofen and motrin?
– Are you under severe stress lately?
– Do you drink alcohol?
PMH:
– Have you ever been diagnosed with gastritis or other GI conditions in the past?
– Do you have any heart conditions?
– Do you have any lung disease?
– Have you ever been hospitalized?
MEDs: None
Allergies: Are you allergic to any foods or medications?
FH:
– How is your parents/siblings’ health?
– Is there a history of gastritis in the family?
– Is there a history of autoimmune disease in the family?
– Is there a history of heart disease in the family?
– Is there a history of cancer in the family?
Social Hx:
– Do you smoke?
– Do you drink alcohol?
– Do you use recreational drugs?
Health Related Behaviors:
– Do you exercise regularly?
– Do you follow a healthy diet?
– What kind of foods do you normally eat?
Review of Systems (ROS): See Below
– Constitutional/General – Feeling unwell, in pain.
– Cardiac – Do you have an irregular heartbeat, racing heart, chest pains, swelling of feet or legs, pain in legs with walking?
– Respiratory – Do you have shortness of breath, night sweats, prolonged cough, wheezing, or sputum production?GI – Severe epigastric pain that is worse after eating x 3 weeks. Symptoms are accompanied by nausea but patient denies vomiting or diarrhea at this time. Reports stools as “normal” in color and consistency.
– Do you have heartburn?
– Are you intolerant to certain foods?
– Any blood in stools?
Psychiatric
– Do you feel anxious?
– Do ever feel like hurting yourself or others?
OBJECTIVE
Vital signs – Not provided in this exercise.
Physical exam findings:
– General: Awake, alert and oriented to time, person, place, and situation. In distress due to abdominal pain. Well developed, hydrated and nourished.
– Cardiac: Inspect the chest for appearance. Check if PMI is visible and palpated in the 5th intercostal space at the midclavicular line. Auscultate heart rate and rhythm. Check for murmurs, gallops, or rubs. Check if S1 and S2 are heard and normal in intensity.
– Respiratory: Inspect chest wall for symmetric and deformity. Check for tenderness and signs of respiratory distress. Auscultate lung sounds in all lobes. Perform percussion of all lung fields.
– Abdominal: Inspect if abdomen is soft, symmetric, and distended. Check for visible lesions or scars. Check if aorta is midline without bruit or visible pulsation. Check if umbilicus is midline without herniation. Auscultate bowel sounds in all four quadrants. Check for masses, hepatomegaly, or splenomegaly.
– Psychiatric: Appropriate mood and affect noted. Good judgement and insight. Check for suicidal or homicidal ideation.
ASSESSMENT – DIAGNOSIS
Working diagnosis: 2022 ICD-10-CM Diagnosis Code K21.9 Gastro-esophageal reflux disease without esophagitis (ICD10Data, 2022).
Pertinent Positive: Severe epigastric pain that is worst after eating, nausea
Pertinent Negative: Denies vomiting
Differential Diagnosis 1: 2022 ICD-10-CM Diagnosis Code K29.70 Gastritis, unspecified, without bleeding (ICD10Data, 2022).
Pertinent Positive: Severe epigastric pain that is worst after eating, nausea
Pertinent Negative: Denies vomiting
Differential Diagnosis 2: 2022 ICD-10-CM Diagnosis Code K27 Peptic ulcer, site unspecified (ICD10Data, 2022).
Pertinent Positive: Severe epigastric pain that is worst after eating, nausea
Pertinent Negative: Denies vomiting
PLAN
Tests:
H. Pylori stool antigen test to r/o gastritis and PUD (Mayoclinic, 2022)
Education (2022 AJG Guidelines):
– Elevate the head of the bed
– Reduce fat intake
– Quit smoking
– Remain upright three hours or more after meals
Medications (2022 AJG Guidelines):
– 8 week trial of empiric proton pump inhibitors (PPIs) once daily before a meal
– Over-the-counter antacids and antirefluxants
Referrals
– GI referral for endoscopy if symptoms don’t resolve after 8 weeks trial of PPI.