INITIAL HISTORY: Tom is a 47 year old male who presents with gradual onset of dy

Question

INITIAL HISTORY:

Tom is a 47 year old male who presents with gradual onset of dyspnea on exertion and fatigue. He also complains of frequent dyspepsia with nausea and occasional epigastric pain. So far you only know that he has a history of alcohol abuse.

Part Two

He says he has not had his usual energy levels for months; dyspnea has become much worse in the last few weeks which is why he came in. Tom denies chest pain, orthopnea, edema, cough, wheezing, or recent infections. He states he has occasional episodes of hematemesis after drinking heavily, and subsequently has had several days of dark stools. Tom consumes up to 2 six-packs of beer a day for the past 8 years since losing his job. Nothing seems to make his breathing any better, but antacids help with is epigastric discomfort and dyspepsia.

PAST MEDICAL HISTORY:

Denies history of cardiac or pulmonary disease

Diagnosed with duodenal ulcer in the past and was on “3 drugs at once” for a while 2 years ago, but stopped taking them due to the expense

His only surgical history was a childhood tonsillectomy

De does not smoke or take any medications except for over the counter antacids

He has no known allergies

PHYSICAL EXAMINATION:

Thin and pale white male looking older than his stated age with no acute distress

T = 37 C orally; P = 95 and regular; RR = 16 and unlabored; B/P = 128/72 sitting

Skin, HEENT, Neck:

Skin pale without rash, no spider angiomata

Sclera pale with no icterus

PERRLA, fundi without lesions

Pharynx is clear without postnasal drainage

NO thyromegaly, adenopathy, or bruits

Lungs, Cardiac:

Good lung expansion, lungs clear to auscultation and percussion

PMI at 5th intercostal space at midclavicular line

Heart rhythm regular with a grade II/VI systolic ejection murmur at left sternal border

No gallops, heaves, or thrills

Abdomen, Rectal:

Abdomen nondistended; bowel sounds present

Liver 8 cm. At midclavicular line

Moderate epigastric tenderness without rebound or guarding

Prostate not enlarged and nontender

Stool guaiac positive

Extremities, Neurological:

No joint deformity, muscle tenderness or edema

Alert and oriented X 3

Strength is 5/5 throughout and sensation intact

Gait normal. DTR 2 + and symmetrical throughout

Discussion questions part two:

1.) What are the pertinent positives and negatives on examination related to his presenting problem?

2.) What is your differential diagnosis at this time?

3.) What laboratory studies should be obtained at this time?

Explanation / Answer

1. Keeping in view the history of deodenal ulcer, hematemesis, bloody stool, stool guaiac positive, the person is suspected to suffer from chronic gastritis. There are no symptoms of cardiac, pulmonary, or any other systemic abnormalitites. Chronic duodenal or peptic ulceration also is considered.

2. The person consumes alcohol, and has a previous history of duodenal ulcer. Medication was discontinued without proper diagnosis of the prognosis of the ulcer. The person may be suffering from dyspneoa due to decreased hemoglobin count, which may be the reason for fatigue also.

3. Upper and duodenal endoscopy, blood tests to determine hemoglobin, fecal occult blood test are the preliminary diagnosis suggested.

Related Questions

Navigate

• Browse (All)
• Browse I
• Subjects

Integrity-first tutoring: explanations and feedback only — we do not complete graded work. Learn more.