RESPONSE 1:<\/p>\n
#1, 50-year-old female, bitter taste in mouth<\/p>\n
SUBJECTIVE<\/p>\n
Biographical Data:\u00a050-year-old female<\/p>\n
Source:\u00a0self<\/p>\n
CC:\u00a0complains of being wakened up at night with a bitter taste in her mouth about four times per week for the past two months<\/p>\n
HPI\/ROS:\u00a0Patient (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.\u00a0 She states it is interfering with her sleep, and she is concerned.\u00a0 Other questions of interest would include:\u00a0<\/p>\n
Has this ever happened before? If yes, when, what was the\u00a0diagnosis,\u00a0and how was it treated? Did the treatment work until now?\u00a0<\/p>\n
Does it happen during the day?\u00a0<\/p>\n
Is it intermittent or continuous? How long do the episodes last?<\/p>\n
What helps it?\u00a0 What makes it worse?\u00a0 Have you taken any medications for it?<\/p>\n
Can you distinguish other tastes?\u00a0 Sour? Sweet? Salty? Metallic? Do you have loss of taste?<\/p>\n
Did you start any new medications recently?<\/p>\n
Any dental problems? Pain? Cavities? Dental work? Sores or abscesses in mouth, gums, throat? Any recent nasal congestion or URI symptoms?<\/p>\n
Any difficulty smelling?\u00a0<\/p>\n
Heartburn or reflux?<\/p>\n
Any weight loss? Fatigue? Fever?\u00a0<\/p>\n
PMH:\u00a0<\/p>\n
History of a precipitating event?\u00a0<\/p>\n
Recent trauma?<\/p>\n
Recent medical procedure?<\/p>\n
Cancer therapy (chemo or radiation)?<\/p>\n
Do you have any endocrine or neurological disorders?\u00a0<\/p>\n
When is the last time you have seen a dentist?<\/p>\n
Allergies:\u00a0Ask about allergies to medications, foods, latex, pets, environment and what happens when exposed?<\/p>\n
Medications:\u00a0Ask what medications she is currently taking?\u00a0 Prescription? OTC? Herbal? Supplements? Vitamins?\u00a0<\/p>\n
Family History:\u00a0Ask about family history of mother, father, maternal and paternal grandparents, siblings, health status, diagnosis, age at death, cause?\u00a0<\/p>\n
Personal and Social Hx:\u00a0<\/p>\n
Do you drink alcohol? How often? How much?\u00a0<\/p>\n
Do you use illicit drugs?\u00a0 If historical, last time using?\u00a0<\/p>\n
Do you smoke cigarettes?\u00a0 How many packs\/day, for how long? Vape?\u00a0 Marijuana (ask because these days people don\u2019t always categorize THC as an \u201cillicit drug\u201d)?\u00a0\u00a0<\/p>\n
What is your diet like?\u00a0 The last 3 days give specifics.<\/p>\n
Have you traveled?\u00a0 When\/where?\u00a0<\/p>\n
OBJECTIVE<\/p>\n
General \u2013\u00a0(VS, Ht, Wt, BMI, appearance, apparent distress, cooperative, alert\/oriented, obese, dress)<\/p>\n
Skin \u2013\u00a0(warm, dry, turgor, soft, rashes, lesions, masses, pigmentation\/discoloration, nodules, lacs, ulcerations, nail changes, normal\/abnormal hair distribution, hair loss)<\/p>\n
HEENT – Assess:\u00a0Face\/sinus tenderness,\u00a0oral 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?\u00a0 Dry eyes?\u00a0<\/p>\n
Neck:\u00a0swollen cervical glands? Thyroid swelling, nodules?<\/p>\n
Respiratory:\u00a0Breath sounds in all fields<\/p>\n
Cardiac:\u00a0Rate, rhythm, cardiac sounds<\/p>\n
Neurological:\u00a0Cognitive and cranial nerve function?<\/p>\n
Diagnostic:\u00a0labs, xrays, other clinicians, old findings<\/p>\n
ASSESSMENT<\/p>\n
(www.icd10data.com)<\/p>\n
1. working diagnosis \u2013\u00a0Unspecified disturbance of smell and taste, R43.9<\/p>\n
Pertinent positives: bitter taste in mouth x2 months (phantogeusia \u2013\u00a0Phantogeusia is a non-triggered, intermittent, or permanent taste distortion which includes complaints such as metallic, bitter, sour, salty, and sweet tastes\u00a0(Bhanot & Sharma, 2017).\u00a0\u00a0<\/p>\n
2. differential diagnosis \u2013\u00a0Periodontal disease,\u00a0K05.6<\/p>\n
Pertinent positives: bitter taste in mouth, loose teeth (?), dental abscess (?), necrotizing gingivitis (?)\u00a0(Bhanot & Sharma, 2017)<\/p>\n
Pertinent negatives: no halitosis (?), no inflamed gingiva (?), no loose teeth (?), no decay (?)\u00a0(Bhanot & Sharma, 2017)<\/p>\n
3. differential diagnosis \u2013\u00a0Upper respiratory infection, J06.9<\/p>\n
Pertinent positives: Taste disturbance, respiratory (or post-respiratory) infection (?)\u00a0(Bhanot & Sharma, 2017)<\/p>\n
Pertinent negatives: no congestion (?), no hx of URI\u00a0(Bhanot & Sharma, 2017)<\/p>\n
PLAN<\/p>\n
1. New tests or orders:<\/p>\n
Taste threshold test\u00a0\u2013\u00a0Using taste test strips is the most efficient way to test taste thresholds.\u00a0 This is the most commonly used, credible test for dysgeusia. Four categories of taste are tested including sweet, sour, salty, and bitter.\u00a0\u00a0(Jafari et al., 2021)<\/p>\n
Taste quadrant test\u00a0\u2013\u00a0This test can measure specific areas of the tongue and oral cavity, rather than just the overall qualitative results.\u00a0 It measures four quadrants of the tongue and two sides of the soft palate.\u00a0\u00a0(Jafari et al., 2021)<\/p>\n
CBC<\/p>\n
B12<\/p>\n
Iron<\/p>\n
Zinc<\/p>\n
Calcium<\/p>\n
Potassium<\/p>\n
HgbA1c<\/p>\n
BUN<\/p>\n
Thyroid studies\u00a0<\/p>\n
(Bhanot & Sharma, 2017)\u00a0(Jafari et al., 2021)<\/p>\n
2. Do you need referral to a specialist?\u00a0\u00a0Pending labs\/diagnosis<\/p>\n
3. What discharge instruction\/education will you give the patient?\u00a0<\/p>\n
Use non-metallic silverware<\/p>\n
Avoid metallic or bitter-tasting foods<\/p>\n
Increase\u00a0protein intake<\/p>\n
Flavor foods with spices and seasonings<\/p>\n
Serve cold food to reduce unpleasant taste or odor<\/p>\n
Brush teeth often<\/p>\n
Use\u00a0mouthwash<\/p>\n
Use sialogogues such as sugar-free gum or sour-tasting drops that stimulate the\u00a0taste buds<\/p>\n
Reassurance<\/p>\n
(Jafari et al., 2021)<\/p>\n
4.\u00a0 How soon should the patient come back for follow up?\u00a0\u00a0RTC in 2 weeks to discuss lab results.<\/p>\n
5.\u00a0 Medications –\u00a0None<\/p>\n
RESPONSE 2:<\/p>\n
Choice #2 – 48-year old male GI symptoms<\/p>\n
SUBJECTIVE<\/p>\n
CC \u2013 \u201cMy stomach hurts and I\u2019m nauseated for about 3 weeks, especially after eating\u201d.
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 \u201cnormal\u201d 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?<\/p>\n
PMH:\u00a0
– 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?<\/p>\n
MEDs: None<\/p>\n
Allergies: Are you allergic to any foods or medications?<\/p>\n
FH:\u00a0
– How is your parents\/siblings\u2019 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?<\/p>\n
Social Hx:
– Do you smoke?
– Do you drink alcohol?
– Do you use recreational drugs?<\/p>\n
Health Related Behaviors:
– Do you exercise regularly?\u00a0
– Do you follow a healthy diet?
– What kind of foods do you normally eat?<\/p>\n
Review of Systems (ROS): See Below<\/p>\n
– Constitutional\/General \u2013 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 \u201cnormal\u201d in color and consistency.\u00a0
– Do you have heartburn?
– Are you intolerant to certain foods?\u00a0
– Any blood in stools?<\/p>\n
Psychiatric\u00a0
– Do you feel anxious?
– Do ever feel like hurting yourself or others?
OBJECTIVE<\/p>\n
Vital signs \u2013 Not provided in this exercise. \u00a0<\/p>\n
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.\u00a0
– 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.\u00a0
– 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.\u00a0
– Psychiatric: Appropriate mood and affect noted. Good judgement and insight. Check for suicidal or homicidal ideation.<\/p>\n
ASSESSMENT – DIAGNOSIS\u00a0<\/p>\n
Working diagnosis: 2022 ICD-10-CM Diagnosis Code K21.9 Gastro-esophageal reflux disease without esophagitis (ICD10Data, 2022).<\/p>\n
Pertinent Positive: Severe epigastric pain that is worst after eating, nausea
Pertinent Negative: Denies vomiting\u00a0<\/p>\n
Differential Diagnosis 1: 2022 ICD-10-CM Diagnosis Code K29.70 Gastritis, unspecified, without bleeding (ICD10Data, 2022).<\/p>\n
Pertinent Positive: Severe epigastric pain that is worst after eating, nausea
Pertinent Negative: Denies vomiting\u00a0<\/p>\n
Differential Diagnosis 2: 2022 ICD-10-CM Diagnosis Code K27 Peptic ulcer, site unspecified (ICD10Data, 2022).<\/p>\n
Pertinent Positive: Severe epigastric pain that is worst after eating, nausea
Pertinent Negative: Denies vomiting\u00a0<\/p>\n
PLAN
Tests:\u00a0
H. Pylori stool antigen test to r\/o gastritis and PUD (Mayoclinic, 2022)<\/p>\n
Education (2022 AJG Guidelines):
– Elevate the head of the bed
– Reduce fat intake
– Quit smoking
– Remain upright three hours or more after meals<\/p>\n
Medications (2022 AJG Guidelines):
– 8 week trial of empiric proton pump inhibitors (PPIs) once daily before a meal\u00a0
– Over-the-counter antacids and antirefluxants\u00a0<\/p>\n
Referrals
– GI referral for endoscopy if symptoms don\u2019t resolve after 8 weeks trial of PPI.<\/p>\n","protected":false},"excerpt":{"rendered":"
RESPONSE 1: #1, 50-year-old female, bitter taste in mouth SUBJECTIVE Biographical Data:\u00a050-year-old female Source:\u00a0self CC:\u00a0complains 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:\u00a0Patient (name) is a 50-year-old female who complains of being awakened 4x\/week with a bitter taste in […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[10],"class_list":["post-93722","post","type-post","status-publish","format-standard","hentry","category-research-paper-writing","tag-writing"],"_links":{"self":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/93722","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/comments?post=93722"}],"version-history":[{"count":0,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/93722\/revisions"}],"wp:attachment":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/media?parent=93722"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/categories?post=93722"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/tags?post=93722"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}