Chief Complaint
“This morning after breakfast, I had sudden, severe pain in my abdomen and I vomited a couple of times, but the pain still persists. It hurts here, above my belly button, and feels like it goes straight through to my back.”
(Matsko, 2017)
History of Present Illness
Mr. Walker, a 50-year-old minister, presents with a history of a sudden onset of acute upper central abdominal pain radiating to his back. The pain began shortly after his morning meal and he vomited several times, without relief of his pain.
Past Medical History
- Appendectomy at age 25
- Tonsillectomy at age 7
- Hypertension (diagnosis 5 years ago)
- Pre-diabetic (diagnosis 6 months ago)
Pertinent Family History
- Sister, 45, had cholelithiasis 2 years ago.
- Brother, 54, had a cholecystectomy for acute cholecystitis and cholelithiasis 5 years ago.
- Mother, 75, had a cholecystectomy for acute cholecystitis and cholelithiasis 13 years ago.
Pertinent Social History
- Patient admits to drinking “my fair share of bourbon-whiskey” most evenings.
- Never a smoker.
Allergies
- No known allergies.
Current Medications
- Aspirin – 325mg per day (to minimize risk of heart attack)
- Propanolol – 30mg per day (for hypertension)
- Hydrochlorthiazide – 25mg per day (for hypertension)
Focused Physical Exam
(Gomerblog, 2016)
- Vitals
- BP: 110/60 mmHg
- HR: 110 bpm (tachycardia)
- RR: 24/min
- Temp: 100.6F (fever)
- Pain: 8 out of 10
- Physical Exam
- Cardio: no murmurs or extra cardiac sounds
- Respiratory: lungs clear and equal bilaterally
- Abdomen: tender in the mid-epigastrium with guarding and rebound tenderness
Next up: List of possible differential diagnoses
- Labs to be Ordered
- Complete Blood Count (CBC)
- Comprehensive Metabolic Panel
- Serum lipase and amylase, CRP, interleukins
- Serum troponin
- Further Diagnostics Required
- CT scan w/ contrast
- Abdominal ultrasound
- ECG