Patient Initials: XY Age: 60 Sex: M
SUBJECTIVE DATA:
Client Complaints: Acute abdominal pain after eating with nausea
HPI: The patient came in with complaints of acute abdominal pain. He verbalized that his acute onset of abdominal pain started last evening after eating. He is also experiencing a gnawing hunger pain in the umbilical area. He also feels nauseous but no vomiting. He felt warm and sweaty last night that he believed he may have had a fever. His symptoms subsided after he sat up for a few hours on a chair. He had similar symptoms in the past but not as severe as the last 24 hours. He rated his pain as 10 last night, more localized in the periumbilical region, that it kept him awake all night. Today, his pain rate is a 7. In addition, he has been having a heartburn-like symptoms for the past 2 weeks that increased after eating. The heartburn would resolve on its own after few hours and at times, was relieved after taking some over-the-counter antacids. He sought medical care today due to worsening of his symptoms.
PMH: He has no known allergies. His medications include Propranolol 50mg BID, Zocor 20mg QD, Indocin 50mg Q 6 hours as needed …show more content…
Though some more tests needed to be performed to confirm the diagnosis of peptic ulcer disease, there is a high probability that the patient developed ulcers on the account of his presenting signs and symptoms. Most ulcers are caused by an infection with a type of bacteria called Helicobacter pylori (H. pylori). Risk factors to peptic ulcer disease include use of painkillers like NSAIDS, excessive drinking of alcohol, age 50 or older, infection with H.pylori bacterium, and have a family history of ulcers. Symptoms of ulcer include a gnawing or burning pain in the middle or upper stomach between meals or at night, bloating, heartburn, nausea or
SUBJECTIVE DATA:
Client Complaints: Acute abdominal pain after eating with nausea
HPI: The patient came in with complaints of acute abdominal pain. He verbalized that his acute onset of abdominal pain started last evening after eating. He is also experiencing a gnawing hunger pain in the umbilical area. He also feels nauseous but no vomiting. He felt warm and sweaty last night that he believed he may have had a fever. His symptoms subsided after he sat up for a few hours on a chair. He had similar symptoms in the past but not as severe as the last 24 hours. He rated his pain as 10 last night, more localized in the periumbilical region, that it kept him awake all night. Today, his pain rate is a 7. In addition, he has been having a heartburn-like symptoms for the past 2 weeks that increased after eating. The heartburn would resolve on its own after few hours and at times, was relieved after taking some over-the-counter antacids. He sought medical care today due to worsening of his symptoms.
PMH: He has no known allergies. His medications include Propranolol 50mg BID, Zocor 20mg QD, Indocin 50mg Q 6 hours as needed …show more content…
Though some more tests needed to be performed to confirm the diagnosis of peptic ulcer disease, there is a high probability that the patient developed ulcers on the account of his presenting signs and symptoms. Most ulcers are caused by an infection with a type of bacteria called Helicobacter pylori (H. pylori). Risk factors to peptic ulcer disease include use of painkillers like NSAIDS, excessive drinking of alcohol, age 50 or older, infection with H.pylori bacterium, and have a family history of ulcers. Symptoms of ulcer include a gnawing or burning pain in the middle or upper stomach between meals or at night, bloating, heartburn, nausea or