THE HISTORY AND PHYSICAL (H&P)
Patient’s Details
Initials: P.S. Age: 34 years Race: African-American Gender: Male
“I have a burning sensation on my chest usually after eating. Sometimes I feel like swallowed food is moving up my chest towards the mouth. These symptoms worsen at night when I am lying down.”
A 34-year-old African-American male has come to the clinic unaccompanied. The patient’s chief complaint is a burning sensation on his chest which usually occurs after eating and are worsened at night when he is in a lying position. The patient sometimes feels as if swallowed food is moving up his chest towards the mouth, a condition known as regurgitation. Other associated symptoms include a bitter taste in the mouth, shortness of breath, and chest pain. As reported by P.S., his symptoms have lasted for more than 4 weeks.
Although the symptoms do not occur every day, the patient indicates that they can happen either once or twice a week. Eating late at night and consuming fatty or fried foods trigger the symptoms while they rarely happen when he eats dinner early. P.S. is not taking any medications to improve his current symptoms. However, he is currently on Orlistat 120 mg which he is taking orally three times daily to manage obesity that he has been having for the past one year.
III. Past medical history (PHx)
P.S. received the following vaccines according to schedule;
His last tetanus booster was given at the age of 26 years. His last influenza vaccine was a year ago. The patient indicates that he has not been vaccinated against COVID-19.
Denies a history of adulthood hospitalizations. He was diagnosed with obesity in February 2021.
Denies surgical history
No known drug or food allergies reported.
Orlistat 120 mg taken orally three times a day
P.S. denies using any complimentary treatments to manage his current symptoms
Father has been having stroke for the past five years. Mother has no medical condition. Paternal grandparents are deceased while maternal grandparents are alive. The patient’s paternal uncle has obesity. P.S. is the first born in a family of five children. His four siblings are all alive.
P.S. is a university graduate. He is a veterinary doctor and is employed in a livestock company. He is married to one wife and they are blessed with 2 kids, a boy and a girl. P.S. stays with his family in a rental family in town. He occasionally consumes alcohol whenever he goes out to party with friends. He denies cigarette smoking. He also denies using illicit drugs such as marijuana, cocaine, or heroin. P.S. is on a restricted diet as advised by the physician after he was diagnosed with obesity.
His diet mostly comprises of fatty foods because Orlistat should be taken with foods that contain fats. He engages in exercise daily by going to a gym. He also plays soccer with his friends over the weekends. However, the patient states that he started to engage in exercise just a year ago when he was diagnosed with obesity.
General: Reports that his weight has been reducing gradually since he started to use obesity medications. Denies nausea, vomiting, or fever. Reports regurgitation, heartburn, chest pain, and shortness of breath.
Skin: Denies hair loss or thinning. No bruises, pruritus, redness, or rashes on the skin reported. Does not report brittle nails or nail breakage.
HEENT:
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