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Additional Diagnostic Information of The Patient Case Study

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Health & Medical

Type

Case Study

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funzf1981

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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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Tags: medical history pain killers physical examination pathological conditions Acid Peptic disease