Case
iHuman=Case - Study - Jacob Abraham = 58yrs Old Male =
CC= Burning chest discomfort with SCREENSHOT ….
Ihuman Jacob
Abraham 58y/o
Reason for encounter: Burning chest discomfort
:Questions
1. Howcan Ihe lpy ou toda y
a. “ Ivebeenha ving somec hes tdisc omf ort.
”
2. Doyou ha vean yot he rs ympt omsorc on cer nswes hou l
dd i
sc uss?
3. When didt hepa ini ny ourc he sts tart
4. I
syourc he stpa inpr ec ipitated byex ercise
5. Doesan ything mak et hepa i
ni ny ou rc hes tbe terorwor se
6. Wheremor epr ec i
s elyist hepa ini ny ou rc hes t
7. Howsev ere( 1-10 )ist hepa ini ny ourc hes t
a. 4- 5/10
8. Doesthepa i
ni ny ou rc he strad i
at es omep lac ee l
s e?
a. Mov esup intone ck( po inti
ng t
oada msapp le)
9. Hav
ey ou had t
hepa ininy ourc hes tbe fore ?
10
.Anyc han ge iny ou rc he stpa i
ns i
nc eitbeg an
11
.Howl ong doe sy ou rc he stpa inl ast
a. La s t30 minu tes
12
.Howof ten doe st hisc he stpa ino cur
13.Doyou drinkal coho l?If s owha tdo you drinkand ho wman ydr i
nkspe rda y
?
a. 1d rinkpo stdi nne r,no tQni gh t.
14.Canyou t
ellmeabou ty ou rdiet ?Wha tdo y ouno rmall yea t?
15.Doyou ha vean ypr oblemswi thf ati
gue ,di ffi
cul t
ys l
eep i
ng ,un intenti
ona lweightl
ossorgai
n
16
.Doy ou expe rien c es hortne ss ofbr ea th,whee zing,diffi
cul t
ycat chingyou rbreat
h
17
.Doy ou ha vepr ob l
emswi thnau s ea vomi ti
ng consti
pa ti
on diarrhe acoffee gr
ound si
nyourvomit
18
.Hasdr i
nk i
ng alcoho lev erc au s ey ou prob l
ems ?
19.Havey ou everf el ty ou needed t
oc utdo wnon you rdr i
nk ing ?
20.Havey ou everbeen anno yed atan yone fors ugge sti
ng tha tyou cutba ckiny oural
coho
lconsumpt
i
on?
21
.Doy ou needan al coho li
cdr i
nkfirs thing i
nt he mor ning ?
22.Whenand wha tdi dy ou las tdr i
nk ?
23.Doyou pres en tl
yha v ehe artbu rn,af oodo rac i
dt as t
ei ny ou rmou t
h?
24
.Doy ou ha veahi s tor yofhe artbu r
n?
25
.Doy ou ha vean ypr ob lemswi thne r
vou sne s, sdepress ion ,lackofi nt
er est
,sadne ss
…
26
.Doy ou ha vedi ffi
cul tybr ea thing
27
.Hasan yone s ug ge s ted tha tyou shou ldr edu cethe amoun tofal coholy oudri
nk
:::MISSING
in PMH 1
in Etiology 1
Diagnosis: GERD
:Differential diagnosis
:Madalyn put
Unstable angina -
GERD -
Pneumonia -
, Aortic dissection -
Acute coronary syndrome -
Sprain/strain -
Gastritis -
iHuman=Case - Study - Jacob Abraham = 58yrs Old Male =
CC= Burning chest discomfort with SCREENSHOT ….
Ihuman Jacob
Abraham 58y/o
Reason for encounter: Burning chest discomfort
:Questions
1. Howcan Ihe lpy ou toda y
a. “ Ivebeenha ving somec hes tdisc omf ort.
”
2. Doyou ha vean yot he rs ympt omsorc on cer nswes hou l
dd i
sc uss?
3. When didt hepa ini ny ourc he sts tart
4. I
syourc he stpa inpr ec ipitated byex ercise
5. Doesan ything mak et hepa i
ni ny ou rc hes tbe terorwor se
6. Wheremor epr ec i
s elyist hepa ini ny ou rc hes t
7. Howsev ere( 1-10 )ist hepa ini ny ourc hes t
a. 4- 5/10
8. Doesthepa i
ni ny ou rc he strad i
at es omep lac ee l
s e?
a. Mov esup intone ck( po inti
ng t
oada msapp le)
9. Hav
ey ou had t
hepa ininy ourc hes tbe fore ?
10
.Anyc han ge iny ou rc he stpa i
ns i
nc eitbeg an
11
.Howl ong doe sy ou rc he stpa inl ast
a. La s t30 minu tes
12
.Howof ten doe st hisc he stpa ino cur
13.Doyou drinkal coho l?If s owha tdo you drinkand ho wman ydr i
nkspe rda y
?
a. 1d rinkpo stdi nne r,no tQni gh t.
14.Canyou t
ellmeabou ty ou rdiet ?Wha tdo y ouno rmall yea t?
15.Doyou ha vean ypr oblemswi thf ati
gue ,di ffi
cul t
ys l
eep i
ng ,un intenti
ona lweightl
ossorgai
n
16
.Doy ou expe rien c es hortne ss ofbr ea th,whee zing,diffi
cul t
ycat chingyou rbreat
h
17
.Doy ou ha vepr ob l
emswi thnau s ea vomi ti
ng consti
pa ti
on diarrhe acoffee gr
ound si
nyourvomit
18
.Hasdr i
nk i
ng alcoho lev erc au s ey ou prob l
ems ?
19.Havey ou everf el ty ou needed t
oc utdo wnon you rdr i
nk ing ?
20.Havey ou everbeen anno yed atan yone fors ugge sti
ng tha tyou cutba ckiny oural
coho
lconsumpt
i
on?
21
.Doy ou needan al coho li
cdr i
nkfirs thing i
nt he mor ning ?
22.Whenand wha tdi dy ou las tdr i
nk ?
23.Doyou pres en tl
yha v ehe artbu rn,af oodo rac i
dt as t
ei ny ou rmou t
h?
24
.Doy ou ha veahi s tor yofhe artbu r
n?
25
.Doy ou ha vean ypr ob lemswi thne r
vou sne s, sdepress ion ,lackofi nt
er est
,sadne ss
…
26
.Doy ou ha vedi ffi
cul tybr ea thing
27
.Hasan yone s ug ge s ted tha tyou shou ldr edu cethe amoun tofal coholy oudri
nk
:::MISSING
in PMH 1
in Etiology 1
Diagnosis: GERD
:Differential diagnosis
:Madalyn put
Unstable angina -
GERD -
Pneumonia -
, Aortic dissection -
Acute coronary syndrome -
Sprain/strain -
Gastritis -
