Age: 50 years
Complaint (CC): Abdominal pain
of Present Illness (HPI): AB is a 50
years old male who presents with abdominal pain that he describes as burning
and gnawing in nature. He also reports that the pain begins after meals
especially when lying down and rises to the middle of his chest.
history: where exactly does he feel the pain and
can he point with one finger? How long ago did he begin to notice the pain and does
he feel it anywhere else apart from the chest for example on his back? Does he
have any specific foods that when taken causes the pain. does he feel nauseated
when the pain is there, any associated vomiting, diarrhea or constipation, pain
with swallowing or does he have any fevers accompanying the pain? Is there
anything he does that provides some measure of relief from the pain and what is
it if any? How severe is the pain and does it hinder his normal daily
activities? Has he lost any weight or seen any changes in the color of his
stools?Has he visited any health center to have his symptoms checked and if so
has he been offered any help so far?
Current Medications: is he currently on any medications
especially painkillers such as paracetamol or aspirin? How long has he used the
specific drug if any and for what purpose?
and Drug Allergies: Does he have any
allergies to foods, drugs and other substances?
Past Medical History (PMH): Does he have any history of prior admissions into a hospital for
treatments, surgery or blood transfusion? Has he ever been treated for peptic
Family and Social
History: does he drink
alcohol, use drugs of recreation, smoke cigarettes or is he regularly exposed
to cigarette fumes? Does any member of his family have ulcer disease or reflux
disease or any chronic disease such as heart disease, diabetes or asthma? Is he
married and does he have any children? Does he have any siblings and what is
their health status?
Cardiovascular: does he
experience easy fatigability, breathlessness or have any palpitations?
Central Nervous System: has he
experienced any changes in his vision, any headaches or loss of consciousness?
Respiratory: does he experience any difficulty in
breathing, chest pains on breathing or coughs?
Genitourinary: has he
noticed any change in his urinary habits in terms of frequency, color, smell,
pain or difficulty initiating micturition?
Musculoskeletal: does he
have any problems with his movements?
General Exam: check for
pallor, jaundice, edema, lymphadenopathy and physical appearance
Vital Signs: Temperature,
pulse rate, rate of respiration and blood pressure measurement should be taken.
Inspection: check for any obvious distention, skin changes, abnormally enlarged
abdominal blood vessels, surgical marks and visible peristalsis.
Palpation: palpate for any tenderness and not the tender area if any, obvious masses
and to feel to any changes in abdominal skin temperature.
Percussion: to check for fluid and masses
Auscultation: feel for any change in bowel sounds and abnormal bruits in the abdomen
Reflux Disease: Weakness of the lower esophageal sphincter results in
food being regurgitated back into the esophagus after it has reached the
stomach and mixed with stomach acids causing a burning sensation along the
length of the esophagus (Fock & Poh, 2010).
Hernia: An abnormal or enlarged opening in the diaphragm allows
abdominal contents to be displaced upwards into the thorax. Pathologies in
these abdominal organs are thus felt as chest pains in the thorax (Kahrilas, Lin,
Chen, & Manka, 1999).
Ulcer Disease: Breakage in the epithelial barrier of the
gastro-intestinal tract causes ulceration. If it occurs in the duodenum it
causes peptic ulcers which presents commonly as epigastric pain which can
radiate to the chest and back (Ramakrishnan & Salinas, 2007).
Outlet Obstruction. It is commonly secondary to other disease such as
hiatal hernia or reflux disease or other inflammatory conditions of the Gastrointestinal
tract and can cause stenosis of the pyloric sphincter. This can lead to reflux
disease that will present as chest pains especially after meals (Mohammed,
Benmousa, Almeghaiseeb, & Alkarawi, 2007).
inflammation of the pancreas due to many causes such as alcohol can cause
symptoms such as epigastric pain that is also felt in the back of the chest
especially following meals.
Barium Swallow: allows the taking of specialized
abdominal X-RAYS after the patient swallow a barium tablet that offers contrast
for easy visualization of abdominal lesions. It can be used to diagnose hiatus
hernia and gastro-esophageal reflux disease (Martin-Harris, Logemann,
McMahon, Schleicher, & Sandidge, 2000).
of a tube with a camera into the gastro-intestinal tract though the mouth to
enable the direct visualization of the tract. Used to diagnose many disease
affecting the gastrointestinal system including pancreatitis, advanced reflux disease
and peptic ulcer disease (Graham,
Kato, & Asaka, 2008).
Pylori Antigen test: H. pylori is known to be a common cause of
peptic ulcers. Demonstration of its antigens in a patient’s stool can rule in
peptic ulcer disease. (Monteiro,
De Mascarel, Sarrasqueta, Bergey, Barberis, Talby, & Mégraudgraud, (2001)
Plain chest X-Rays: these can show presence of a structure
that is gas-filled in the retro-cardiac space and provide more evidence for a