Health History Interview and Risk Assessment

SUBJECTIVE:

ID: RS is a 48 year old female. She is a Hispanic Mexican. She came to the clinic alone. She is a reliable source of health information.

CC: “I came here because I have a lot of pain in my abdomen.”

HPI: RS, a 48-year-old Hispanic Mexican, presented to the clinic with complaints of abdominal pain. Her last annual checkup was on February 24, 2023. She reported experiencing abdominal pain. The pain started five months ago, but she has been ignoring it. She noted that the pain is in the upper epigastric part of her abdomen. The pain is more of the pressure type and aggravated when she coughs. She denied having tried any interventions to lessen the pain. Her pain severity score is 7/10.

Past Medical History:

The patient is a known hypertensive. She has a history of surgery and hospitalization. At the age of three, she had a hernia repair. She has, however, not had any recent hospitalizations, surgeries, accidents, or injuries. She is up to date with her vaccines, including covid vaccine. She has yet to take her annual flu vaccine.

Allergies: The patient has no known allergies.
Medications: The patient is currently on enalapril 20mg for the management of hypertension. She denies taking any over-the-counter medications or herbal supplements.
Family History: The patient’s family history is positive for chronic illnesses. Both of her parents are alive. Her mother has hypertension. She also underwent a surgical procedure to correct abdominal hernia. Her maternal grandmother died of diabetes at the age of 78. There are no notable chronic illnesses among her siblings.
Chemicals: The patient is a social drinker. She, however, has a negative history of smoking or recreational drug use.
Diet/exercise/caffein e: The patient is on a regular diet but tries to restrict carbohydrate intake. She exercises mildly.
Sexual/Reproductive History: Her last menstrual period was February 1, 2024. She currently has regular menstrual cycles. The patient has a history of irregular menstruation. She experienced heavy menstrual bleeding on some occasions that prompted an endometriosis examination. She was, however, found not to be having menstruation. She had a pap smear test in January and a mammography in February and is scheduled for a colonoscopy.

Social History

The patient is currently in a monogamous relationship. She is sexually active and engages in sexual activities. She noted that she uses condoms during sexual intercourse. She denies using any other form of contraceptive. She has one child, but they do not live together.

Occupation, marital/relationship/military status & current living situation: The patient works as a Certified Nurse Assistant (CNA). She is not married but has a boyfriend. She lives alone in a rented house. She has never joined the military.
Spiritual/Social Supports: The patient is a Christian. She believes in God. She utilizes musical relaxation to cope with her daily life stressors.
Safety: The patient lives in a house. She noted feeling safe in the environment she lives in. She also denied having experienced any theft in her environment.

Review of Systems

Constitutional: The patient denies experiencing any changes in her weight or appetite loss. She also denies experiencing fever or chills.
Eyes: Denies visual loss, blurriness, or double vision. The patient also denies any color change in her eyes.
Ears, Nose, Throat: The patient has a hearing loss problem in her right ear that resulted after a fall when she was seven years old. She denies experiencing tinnitus, nasal discharge, runny nose, nasal bleeding, or polyps. She also denies having any gum or mouth soreness, sore throat, or swallowing difficulties.
Cardiovascular: The patient denies chest pains, palpitations, or heartbeat irregularities. However, she experiences palpitations when running around.
Respiratory: Denies having any shortness of breath, wheezing, or coughs.
Gastrointestinal: Denies experiencing changes in her bowel movements, diarrhea, or constipation.
Genitourinary: Denies dysuria, hematuria, or vaginal itchiness.
Musculoskeletal: Denies muscular and joint stiffness or muscular weakness.
Integumentary/Breast: Denies any skin color change, breast lumps, lymph node enlargement, or skin mole enlargement.
Neurologic: Denies dizziness, fainting spells, or headaches.
Psychiatric: Denies any unusual behavior or mood changes. She also denies insomnia or depression.
Hematologic/Lymphatic: Denies experiencing unusual bruising, gum bleeding, non-stop bleeding, or swollen lymph nodes.
Endocrine: Denies experiencing frequent urination, weight changes, or excessive thirst.
Allergic/Immunologic: Denies having any known allergies or itchiness and rashes. She has a negative history of an autoimmune disease.

ASSESSMENT:

Risk Assessment:

The patient is at risk of hypertension due to social drinking, a family history of hypertension, and a lack of exercise. Hypertension has a genetic predilection. Persons with close relatives with the disease are more likely to develop the disease than those without. Lack of exercise and alcohol consumption are also known risk factors for hypertension (Kheriji et al., 2023). As evident in the case, the patient has hypertension. She also indulges in social drinking and exercises mildly. These factors place her at risk of developing hypertension.
The patient is also at risk of developing T2DM due to alcohol consumption and lack of exercise. Lack of exercise and alcohol consumption are risk factors for T2DM. Persons who engage in social drinking behaviors and barely exercise are twice as likely to develop diabetes (Kheriji et al., 2023). The risk of developing diabetes also increases with advancing age. Additionally, the propensity to develop diabetes is particularly higher among some races. Accordingly, Hispanics and Blacks are more likely to develop diabetes (Kheriji et al., 2023). The patient in the case is a social drinker and barely exercises. She also belongs to the Hispanic race.
The patient is at risk of developing another hernia. Hernias have a multifactorial etiology, with genetic and environmental factors interplaying in the development of a hernia. Persons with a family history of hernias are at a higher risk of developing hernias. Additionally, a positive history of hernias is a risk factor for developing a hernia (Andrews & Louie, 2021). In the case presented, the patient had a history of hernia, having experienced a hernia when she was three years of age. She also has a positive family history of hernia.

Differential Diagnosis:

The case is of a 48-year-old female presenting with complaints of upper epigastric pain that worsens on cough.

Differential Diagnosis 1

The first differential is hiatal hernia. Hernia is a medical condition in which part of the internal organs protrudes through an opening in the diaphragm. In a hiatal hernia, part of the stomach or other internal organs protrudes through the hiatus. Hiatal hernia is a leading cause of gastroesophageal reflux disease. Although small hernias are asymptomatic, large hernias will manifest with the typical symptoms of GERD. Patients with hiatal hernia will experience upper epigastric pain and other accompanying features suggestive of GERD, such as bloating. Additionally, the upper epigastric pain in the hiatal hernia is worsened by strenuous activities and coughing (Andrews & Louie, 2021). Genetics, history of hernias, previous surgeries, and increased abdominal pressure, especially during pregnancy, are risk factors for developing a hiatal hernia. In this case, the patient presents with upper epigastric pain that worsens with coughing. Additionally, she has a history of surgeries and a hernia. Her mother also had several hernias. These findings are consistent with those of hiatal hernia, indicating a higher likelihood of the condition.

Differential Diagnosis 2

Another differential in this case is peptic ulcer disease (PUD). PUD is characterized by a discontinuation in the gastric epithelium. PUD has a multifactorial etiology, with infection with H-pylori bacteria and chronic use of NSAIDs being implicated in the development of the disease. Epigastric pain is a common manifestation of the disease. Other features of the disease include nausea and vomiting, bloating, hematemesis, and melena stool (Kavitt et al., 2019). The patient in the case presented experienced upper epigastric pain. This warranted the inclusion of this diagnosis in the differentials list. However, the PUD diagnosis was ruled out due to the absence of features supportive of the disease in the case presented.

Differential Diagnosis 3

Gastrosophageal reflux (GERD) disease is another differential diagnosis. GERD is a chronic gastrointestinal disorder characterized by the retrograde flow of gastric contents. The disease typically manifests with symptoms of heartburn, bloating, and regurgitation. It is a common disease among adults, with a global prevalence of 20% among adults. GERD has no known cause. Esophageal dysmotility and lower esophageal sphincter relaxation have been implicated in the development of GERD (Sharma & Yadlapati, 2020). This diagnosis was included in the differential list because of the presence of upper epigastric pain. It was, however, ruled out due to the absence of other supportive features in the patient case presented. As evident in the case, there were no reports of regurgitation, heartburn, or bloating that are highly suggestive of GERD.

Diagnosis:

The presumptive diagnosis in the case presented is a hiatal hernia. Hiatal hernia is characterized by protrusion of the stomach through the hiatus. The common manifestation of a hiatal hernia is upper epigastric pain. The epigastric pain in the hiatal hernia is worsened by cough and other strenuous activities (Andrews & Louie, 2021). This condition is a likely diagnosis in patients with a history of hernia, those with a family history of hernia, and those with a positive history of surgeries and trauma—the patient in the case presented with upper epigastric pain that worsened with coughing. Subjective findings also revealed a positive history of hernia and a family history of hernia. These findings are consistent with those in hiatal hernia and point to this diagnosis.

PLAN:

Diagnostic Plan: Endoscopy can help exclude other conditions, such as esophageal tumors, and also help in documenting esophageal injuries. Manometry may also help rule out motility disorders that mimic reflux disorders.
Therapeutic Plan (meds): Comprehensive management of hernias utilizes pharmacotherapeutic modalities and surgical interventions. Surgical interventions targeted at repairing the hernias are only warranted when the hernia is large. Initial management of hiatal hernia focuses on addressing GERD symptoms. Proton pump inhibitors are effective in this respect. The patient in this case can be started on Esomeprazole 40mg once daily. This will help in lessening esophageal acid exposure.
Referrals: The patient may be referred to a surgeon if the hernia is large.
Education and Follow-up Plan:

The patient is expected to return for a follow-up after ten days. She is expected to have finished the course of the PPI medication by the time she visits the clinic. The patient will be educated on the medications, including the importance of adhering to the PPI medication prescribed to her. In this respect, she will be advised on how to take her medications and the potential side effects. In this case, the patient will take esomeprazole 40mg once daily. Esomeprazole is a PPI that maintains effectiveness in lowering gastric acidity. The potential side effects of esomeprazole include GI disturbances and headaches. She will also be educated on positive health-seeking behavior. In this respect, she will be told to always seek healthcare immediately when she feels unwell. Ignoring pain and any other disease symptoms may be detrimental to her health.

References

Andrews, W. G., & Louie, B. E. (2021). The relationship of hiatal hernia and gastroesophageal reflux symptoms—two-sphincter hypothesis: A Review. Annals of Laparoscopic and Endoscopic Surgery, 6, 41–41. https://doi.org/10.21037/ales.2020.04.01

Kavitt, R. T., Lipowska, A. M., Anyane-Yeboa, A., & Gralnek, I. M. (2019). Diagnosis and treatment of peptic ulcer disease. The American Journal of Medicine, 132(4), 447–456. https://doi.org/10.1016/j.amjmed.2018.12.009

Kheriji, N., Dakhlaoui, T., Kamoun Rebai, W., Maatoug, S., Thabet, M. T., Mellah, T., Mrad, M., Trabelsi, H., Soltani, M., Kabbage, M., Hassine, H. B., Hadj Salah Bahlous, A., Mahjoub, F., Jamoussi, H., Abid, A., Abdelhak, S., & Kefi, R. (2023). Prevalence and risk factors of diabetes mellitus and hypertension in northeast Tunisia calling for efficient and effective actions. Scientific Reports, 13(1). https://doi.org/10.1038/s41598-023-39197-0

Sharma, P., & Yadlapati, R. (2020). Pathophysiology and treatment options for gastroesophageal reflux disease: Looking beyond acid. Annals of the New York Academy of Sciences, 1486(1), 3–14. https://doi.org/10.1111/

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Question

For regular SOAP notes, go to Differential Diagnosis, below. For week 1, the Health History and Risk
Assessment, do risk assessment instead:
Risk Assessment:
The risk assessment is ONLY done for the first assignment; health history. In all other assignments, delete this
section and only include a differential diagnosis list.

Health History Interview and Risk Assessment

1) Risk and brief rationale with reference
2) Risk and brief rationale with reference
3) Risk and brief rationale with reference
Example:
1) Risk of CVA (stroke) due to smoking, age, obesity, and family history
2) Risk of unintentional/accidental death, due to age and gender and CDC mortality statistics (CDC, year).
3) Risk of T2DM; due to family history and obesity

Health History Interview and Risk Assessment