PatientInitials: AB Age: 50 years Gender: MaleSUBJECTIVEDATA:ChiefComplaint (CC): Abdominal painHistoryof Present Illness (HPI): AB is a 50years old male who presents with abdominal pain that he describes as burningand gnawing in nature.
He also reports that the pain begins after mealsespecially when lying down and rises to the middle of his chest.Relevanthistory: where exactly does he feel the pain andcan he point with one finger? How long ago did he begin to notice the pain and doeshe feel it anywhere else apart from the chest for example on his back? Does hehave any specific foods that when taken causes the pain. does he feel nauseatedwhen the pain is there, any associated vomiting, diarrhea or constipation, painwith swallowing or does he have any fevers accompanying the pain? Is thereanything he does that provides some measure of relief from the pain and what isit if any? How severe is the pain and does it hinder his normal dailyactivities? Has he lost any weight or seen any changes in the color of hisstools?Has he visited any health center to have his symptoms checked and if sohas he been offered any help so far?Current Medications: is he currently on any medicationsespecially painkillers such as paracetamol or aspirin? How long has he used thespecific drug if any and for what purpose?Foodand Drug Allergies: Does he have anyallergies to foods, drugs and other substances? Past Medical History (PMH): Does he have any history of prior admissions into a hospital fortreatments, surgery or blood transfusion? Has he ever been treated for pepticulcers before?Family and SocialHistory: does he drinkalcohol, use drugs of recreation, smoke cigarettes or is he regularly exposedto cigarette fumes? Does any member of his family have ulcer disease or refluxdisease or any chronic disease such as heart disease, diabetes or asthma? Is hemarried and does he have any children? Does he have any siblings and what istheir health status? Reviewof Systems:Cardiovascular: does heexperience easy fatigability, breathlessness or have any palpitations?Central Nervous System: has heexperienced any changes in his vision, any headaches or loss of consciousness? Respiratory: does he experience any difficulty inbreathing, chest pains on breathing or coughs?Genitourinary: has henoticed any change in his urinary habits in terms of frequency, color, smell,pain or difficulty initiating micturition?Musculoskeletal: does hehave any problems with his movements?OBJECTIVEPhysicalexaminationGeneral Exam: check forpallor, jaundice, edema, lymphadenopathy and physical appearance Vital Signs: Temperature,pulse rate, rate of respiration and blood pressure measurement should be taken.AbdominalExaminationInspection: check for any obvious distention, skin changes, abnormally enlargedabdominal blood vessels, surgical marks and visible peristalsis.Palpation: palpate for any tenderness and not the tender area if any, obvious massesand to feel to any changes in abdominal skin temperature.Percussion: to check for fluid and massesAuscultation: feel for any change in bowel sounds and abnormal bruits in the abdomenASSESSMENTDifferential diagnoses: Gastro-esophagealReflux Disease: Weakness of the lower esophageal sphincter results infood being regurgitated back into the esophagus after it has reached thestomach and mixed with stomach acids causing a burning sensation along thelength of the esophagus (Fock & Poh, 2010).
HiatusHernia: An abnormal or enlarged opening in the diaphragm allowsabdominal contents to be displaced upwards into the thorax. Pathologies inthese abdominal organs are thus felt as chest pains in the thorax (Kahrilas, Lin,Chen, & Manka, 1999).PepticUlcer Disease: Breakage in the epithelial barrier of thegastro-intestinal tract causes ulceration. If it occurs in the duodenum itcauses peptic ulcers which presents commonly as epigastric pain which canradiate to the chest and back (Ramakrishnan & Salinas, 2007).GastricOutlet Obstruction. It is commonly secondary to other disease such ashiatal hernia or reflux disease or other inflammatory conditions of the Gastrointestinaltract and can cause stenosis of the pyloric sphincter. This can lead to refluxdisease that will present as chest pains especially after meals (Mohammed,Benmousa, Almeghaiseeb, & Alkarawi, 2007).Pancreatitis:inflammation of the pancreas due to many causes such as alcohol can causesymptoms such as epigastric pain that is also felt in the back of the chestespecially following meals.
PLANDiagnostic tests:Barium Swallow: allows the taking of specializedabdominal X-RAYS after the patient swallow a barium tablet that offers contrastfor easy visualization of abdominal lesions. It can be used to diagnose hiatushernia and gastro-esophageal reflux disease (Martin-Harris, Logemann,McMahon, Schleicher, & Sandidge, 2000). Endoscopy:Passageof a tube with a camera into the gastro-intestinal tract though the mouth toenable the direct visualization of the tract.
Used to diagnose many diseaseaffecting the gastrointestinal system including pancreatitis, advanced reflux diseaseand peptic ulcer disease (Graham,Kato, & Asaka, 2008).HelicobacterPylori Antigen test: H. pylori is known to be a common cause ofpeptic ulcers. Demonstration of its antigens in a patient’s stool can rule inpeptic ulcer disease.
(Monteiro,De Mascarel, Sarrasqueta, Bergey, Barberis, Talby, & Mégraudgraud, (2001)Plain chest X-Rays: these can show presence of a structurethat is gas-filled in the retro-cardiac space and provide more evidence for ahiatus hernia.