Tom is a 47 year old male who presents with gradual onset of
dyspnea on exertion and fatigue. He also complains of frequent dyspepsia with
nausea and occasional epigastric pain. So far you only know that he has a
history of alcohol abuse.
He says he has not had his usual energy levels for months;
dyspnea has become much worse in the last few weeks which is why he came in.
Tom denies chest pain, orthopnea, edema, cough, wheezing, or recent infections.
He states he has occasional episodes of hematemesis after drinking heavily, and
subsequently has had several days of dark stools. Tom consumes up to 2
six-packs of beer a day for the past 8 years since losing his job. Nothing
seems to make his breathing any better, but antacids help with is epigastric
discomfort and dyspepsia.
PAST MEDICAL HISTORY:
Denies history of cardiac or pulmonary disease
Diagnosed with duodenal ulcer in the past and was on “3
drugs at once” for a while 2 years ago, but stopped taking them due to the
His only surgical history was a childhood tonsillectomy
De does not smoke or take any medications except for over
the counter antacids
He has no known allergies
Thin and pale white male looking older than his stated age
with no acute distress
T = 37 C orally; P = 95 and regular; RR = 16 and unlabored;
B/P = 128/72 sitting
Skin, HEENT, Neck:
Skin pale without rash, no spider angiomata
Sclera pale with no icterus
PERRLA, fundi without lesions
Pharynx is clear without postnasal drainage
NO thyromegaly, adenopathy, or bruits
Good lung expansion, lungs clear to auscultation and
PMI at 5th intercostal space at midclavicular
Heart rhythm regular with a grade II/VI systolic ejection
murmur at left sternal border
No gallops, heaves, or thrills
Abdomen nondistended; bowel sounds present
Liver 8 cm. At midclavicular line
Moderate epigastric tenderness without rebound or guarding
Prostate not enlarged and nontender
Stool guaiac positive
No joint deformity, muscle tenderness or edema
Alert and oriented X 3
Strength is 5/5 throughout and sensation intact
Gait normal. DTR 2 + and symmetrical throughout
Discussion questions part two:
1. What are the pertinent positives and negatives on examination related to his
2. What is your differential diagnosis at this time?
3. What laboratory studies should be obtained at this time?