Description

Problem Statement on case William Garrett – Version 1

WG is a 50yr old male presenting with abdominal pain for a few months. He has history of dyslipidemia, osteoarthritis, current moderate alcohol use, and 30 pack year smoking. He reports stomach feels tight, acid taste in mouth, kind of burning sense of indigestion. He also reports black colored bowel movements, and clear vomitus with black spots, lasting a couple of days with last events occurring couple months ago. Abdominal pain is slightly relieved with OTC chewable antacids and meals. He denies prescription medication, but states he takes OTC Ibuprofen and Aspirin 81mg daily. He denies diarrhea, constipation, continuous vomiting. Physical exam revealed hyperactive bowel sounds, moderate epigastric tenderness with palpation. Negative for hepatosplenomegaly, hernation, masses, abnormal pulsations. No guarding or rebound tenderness. Digital rectal exam negative.

Problem Statement on case William Garrett – Version 1

WG is a 50 yo male complaining of stomach pain that began a few months ago. He notes the pain is constant. Rates it at 2/10 but it can be as a high as a 6/10. The pain feels like a burning or aching pain. It is located in his upper gut, below his breast bone. He has one episode of coffee ground emesis and some black stools when he first noticed the pain a few months ago but nothing recently. He has some relief of the pain when he eats, for example 2 slices of bread and 2 slices of milk. He has more pain when he does not eat. BS are hyperactive. He has regular bowel movements. Rectal exam negative. He takes an aspirin daily for heart health. He takes Ibuprofen for OA of knees. Hx of 1-ppd cigarette smoker and drinks 7-10 beers weekly. ROS otherwise negative.