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Ms. L. is a 68-year-old woman who presents with complaints of feeling “heartburn
Ms. L. is a 68-year-old woman who presents with complaints of feeling “heartburn” all the time. Problem started a year ago and was intermittent. Pain is worse when lying down to sleep. She complains that upon awakening she has a burning sensation in her throat and epigastric area. Alleviated by Tums in the past. Symptoms have come on more frequently over the last month and Lena now always feels the sensation of heartburn without relief. No nausea or vomiting. Eating pattern normal. Denies difficulty swallowing. Denies constipation or diarrhea. Denies melena.
Medical History
Type II DM
HTN
Surgical history
TAH at age 56
Family History
Father diagnosed with CAD, A-fib, DM, HTN
Mother diagnosed with uterine cancer.
Social history
Lena is widowed. She is retired. Lives alone. Her two adult children live nearby, and Lena sees them every week.
Lena often eats out with her friends.
Tobacco use: 1 PPD x 40 years
2 glasses of wine per night with dinner
Denies drugs.
Not sexually active at this time
Medications
Metformin 1000mg PO BID
Lisinopril 20 mg PO daily
Allergies; NKDA
Physical Exam
General: No distress noted, calm, pleasant, well groomed
Vital signs: 98.6, HR: 88, BP: 140/80, RR: 20, Ht 5’3”, Wt. 175 lbs.
HEENT: Normocephalic, TMs clear, conjunctiva clear, nares patent
Neck: Supple, neg nuchal rigidity, neg lymphadenopathy
Cardiovascular: RRR, S1S2, No murmurs, No gallops, No bruits; Pulses equal and +2 throughout
Abdomen: Soft, nontender, no masses palpated, +BS
Neurologic: No focal findings
Respiratory: CTA B/L
Based on the above scenario, please answer the questions below:
1. Does this scenario require diagnostic studies? if so, which diagnostic studies will be ordered?
2. Discuss 3 differential diagnosis.
3. What is your assessment and treatment plan.
Use APA 7th Edition Format and support your work with at least 2 different peer-reviewed references within 5 years of publication. All paragraphs need to be cited properly. All responses must be in a narrative format and each paragraph must have at least 4 sentences.
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