Reports of intermittent dysphagia and epigastric pain

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Reference no: EM133746736

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HCC Codes , This is a woman who presented with postoperative malabsorption, reports of intermittent dysphagia and epigastric pain especially after eating. Denies having significant abdominal pain or bowel habit changes. Her GERD is well controlled with daily PPI. Controlled diabetes with Metformin. Reports of increased snacking when she arrives for her work Reports of issues with skin especially in her abdomen and her arms Review of Systems Gen.: Denies fever or chills GU: Denies dysuria or hematuria Endocrine: Denies polyuria or polydipsia Cardiac: Denies chest pain or palpitation Respiratory: Denies respiratory distress or wheezing Hematology: Denies bleeding disorder or petechiae Eyes: Denies visual disturbances or pain ENT: Denies congestion or drainage Skin: Denies rash or jaundice Physical Exam Vitals & Measurements T: 36.6 °C (Tympanic) HR: 67 (Peripheral) RR: 16 BP: 111/68 Alert and oriented, obese, no acute distress Lungs: non-labored respiration Abdomen: Soft, obese, nondistended, no acute surgical abdomen, possible umbilical ventral hernia incarcerated but no obstruction or strangulation Heart: Regular rate Musculoskeletal: no tenderness or swelling Skin: Skin is warm, dry and pink, no rashes or Jaundice. Psychiatric: Cooperative, appropriate mood and affect PHQ2 and PHQ9 Little Interest or Pleasure doing things: Not

Reference no: EM133746736

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