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Additional Diagnostic Information of The Patient Case Study

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Health & Medical
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Case Study
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SECENARIO
You are called in the early hours of the morning to a local residence in a lower income area of
town for a 47-year-old man who presents with severe abdominal pain that woke him from his
sleep. As you arrive on scene you notice the home is poorly maintained with a moderate amount
of “junk” around the property. You do not perceive any immediate threats and you approach the
front entrance where the door is open. You announce yourself and your partner. The patient
tells you to come in. As you enter you find the patient, a thin, slightly emaciated man is sitting
on the couch in obvious distress. He has purposeful movements as you approach and ask his
chief complaint. In a clear voice using appropriate words he states he has intermittent abdominal
pain for a week and was awoken from his sleep about 15 minutes ago with intense abdominal
pain. You note his airway is clear, he is breathing rapidly and his pulse is fast and easily
felt. Your partner prepares the stretcher for transport while you continue to ask history questions
and assess vital signs. He describes the pain as an intermittent gas-like” pain in the Epigastric
region. He says he feels like he needs to “burp.” He continues to describe it as a band like
pattern around his upper abdomen and lower chest. It is most intense when he lies flat but seems
to have some relief when sitting upright smoking a cigarette. He took two tablets of Naprosyn to
reduce his typical aches and pains in his knees and ankles. He reports mild nausea but has not
vomited. His last bowel movement was yesterday and described as a loose watery stool of
normal color. He denies chest pain, palpitations nor shortness of breath. He denies chronic
medical conditions and does not take any medications, OTC, prescription or herbal medications
on a regular basis. He also denies recreational drug use but admits from 6-8 beers daily. He
denies allergies.

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On physical examination, his temperature is 35.4°C (95.7°F), blood pressure 111/62 mm Hg,
heart rate 97 beats per minute and respiratory rate of 28 breaths per minute sating 98% on room
air. He is diaphoretic; skin is normal in color and warm. He is unable to get comfortable on the
gurney and is writhing in pain. Mucus membranes are dry, eyes are non-icteric with pupils that
are round, equal and react to light. His lungs are equal, clear to auscultation with good excursion
bilaterally. No rales or rhonchi are found. The abdomen is exquisitely tender on palpation to
the epigastric region and both upper quadrants with focal rebound tenderness and guarding. No
tenderness or masses are felt in the lower quadrants.
1. What other assessment or diagnostic information would you gather on this patient?
In addition to those described in the scenario, the following additional diagnostic information
shall be gathered for this patient:
Information regarding medical history of the patient:
In the history of the patient, a history of usage of pain killers for the typical pains in knees and
joints shall be gathered. This includes the use of NSAIDs, and/or steroids to control these pains.
A longer history of the usage of these medicines implies that the patient may have developed
gastritis due to their overuse or misuse. Furthermore, history shall also be gathered for the other
risk factors of gastritis like infection with H. Pylori in the past, smoking history and the role of
food in controlling or relieving the symptoms of epigastric pain in the past.
Assessment questions

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SECENARIO You are called in the early hours of the morning to a local residence in a lower income area of town for a 47-year-old man who presents with severe abdominal pain that woke him from his sleep. As you arrive on scene you notice the home is poorly maintained with a moderate amount of “junk” around the property. You do not perceive any immediate threats and you approach the front entrance where the door is open. You announce yourself and your partner. The patient tells you to come in. As you enter you find the patient, a thin, slightly emaciated man is sitting on the couch in obvious distress. He has purposeful movements as you approach and ask his chief complaint. In a clear voice using appropriate words he states he has intermittent abdominal pain for a week and was awoken from his sleep about 15 minutes ago with intense abdominal pain. You note his airway is clear, he is breathing rapidly and his pulse is fast and easily felt. Your partner prepares the stretcher for transport while you continue to ask history questions and assess vital signs. He describes the pain as an intermittent “gas-like” pain in the Epigastric region. He says he feels like he needs to “burp.” He continues to describe it as a band like pattern around his upper abdomen and lower chest. It is most intense when he lies flat but seems to have some relief when sitting upright smoking a cigarette. He took two tablets of Naprosyn to reduce his typical aches and pains in his knees and ankle ...
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