Cardiovascular Regular rate and rhythm S1 and S2 present no murmurs rubs

Cardiovascular regular rate and rhythm s1 and s2

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• Cardiovascular: Regular rate and rhythm, S1 andS2 present, no murmurs, rubs, gallops, clicks,precordial movements. No bruits with auscultationover abdominal aorta. No femoral, iliac, or renalbruits. • Respiratory: Chest is symmetrical with respirations.Lung sounds clear to auscultation anteriorly andposteriorly without wheezes, crackles, or cough.AssessmentPrimary: K21.9 Gastroesophageal reflux disease withoutevidence of esophagitis DIfferential: R10.10 Upper abdominal pain, unspecified R10.13 DyspepsiaGastroesophageal reflux disease without evidenceof esophagitis
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Student DocumentationStudent DocumentationModel DocumentationModel DocumentationPlanDiagnostics: none at this time Medications: Ranitidine 150mg po qd x 2 weeks, may continue ifeffective Education: Lifestyle changes such as weight loss, increase inphysical activity, diet changes that may aggravatesymptoms including citrus, coffee, alcohol, chocolateand spicy foods. Elevate head of bed, use wedge pillow for comfort. Eat smaller meals and avoid eating 2-3 hours beforelying down. Referral/Consults: none at this time Follow up: 2 weeks for evaluation of ranitidine andsymptom management Seek medical treatment: Signs of upper/lower GIbleeding, weight loss and chest pain.Diagnostics • Consider testing for helicobacter pylori if symptomspersist Medication • Initiate Ranitidine 150 mg by mouth daily for twoweeks or a proton pump inhibitor Education • Educate on lifestyle changes including weight loss,engagement in daily physical activity, and limitationof foods that may aggravate symptoms includingchocolate, citrus, fruits, mints, coffee, alcohol, andspicy foods • Ms. Jones may elevate the head of her bed orsleep on a wedge-shaped bolster for comfort orsymptom reduction • Encourage to eat smaller meals and to avoid eating2-3 hours before bedtime • Educate on dietary reduction in fat to decreasesymptoms Referral/Consultation • Dietary consult may be beneficial • Refer to GI specialist for upper endoscopy ifsymptoms persist Follow-up Planning • Instruct Tina to seek immediate medical attention ifsigns and symptoms of upper and lowergastrointestinal bleed, weight loss, and chest pain • Return to clinic in 2 weeks for evaluation and followupCommentsIf your instructor provides individual feedback on this assignment, it will appear here.© Shadow Health2018®
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  • Fall '15
  • Gastroesophageal reflux disease

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