S:

YH is an 80 yo female with chief complaint of “acid in my stomach.” She presents with home health aide. Korean translator was used during the encounter. The cutting, epigastric abdominal pain began this morning at 6am, has been continuous, and does not radiate. She reports 9/10 pain severity. This is the first occurrence. The patient did not try any intervention for pain alleviation. Admits anorexia, dyspepsia, one episode of vomiting this AM, chest pain. Denies weight loss, fever, chills, nausea, shortness of breath, hematemesis, diarrhea, dysphagia. Patient reports last week her PMD prescribed Levofloxacin (Levaquin) 500mg PO qd x 5 days for a “cold.” She discontinued the medication after 2 days because it “hurt her stomach.”

PMH: HTN, Hyperlipidemia, Osteoporosis

PSH: Anterior Cervical Discectomy 20 years ago

Allergies: NKDA

Medications: Olmesartan medoxomil (Beneicar) 20mg PO qd, Atorvastatin (Lipitor) 40mg PO qd, Aspirin 81mg PO qd, Alendronate (Fosamax) 70mg PO qwk

FHx: Unknown

SHx: Denies EtOH, Tobacco Use

O:

T 99.0°F | BP 134/86mmHg | P 86 BPM, regular | RR 12 breaths/min, unlabored | SpO2 97% RA

H 64in | W 110 lb. | BMI 18.9

Gen: Alert and oriented x3. Neatly groomed and in no apparent distress. Appears as stated age.

CV: RRR. S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs.

Pulm: Clear to auscultation and percussion bilaterally. Chest expansion symmetrical. No wheezing, rhonchi, rales, dullness.

Abd: Flat, symmetrical. No scars, striae, caput medusa. BS present in all four quadrants. No bruits over aortic/renal/iliac/femoral arteries. Tympanic to percussion throughout. Nontender to light/deep palpation throughout. No guarding or rebound, CVAT, organomegaly. No pulsating abdominal mass.

A:

80 yo female with cutting epigastric abdominal pain, anorexia, dyspepsia, vomiting, and chest pain. Likely GERD.

Differential Diagnosis:

1. Myocardial Infarction
2. Aortic Aneurysm
3. GERD
4. PUD
5. Pancreatitis

P:

Labs:

• Troponin, R/O: MI
• CBC, BMP, Lipase, LFTs, Bilirubin (total, direct, indirect)
• U/A

 

Imaging/Tests:

• EKG, R/O: MI
• CXR
• Abdominal Ultrasound, R/O: Aortic Aneurysm

GERD:

• Start 1L Normal Saline IV
• Start Famotidine (Pepcid) 20mg PO qd
• Start Calcium Carbonate (Maalox) 2 Tabs PO prn; Max 12 tabs/24h
• Start Ondansetron (Zofran) 8mg PO q8h prn

HTN:

• Continue Olmesartan medoxomil (Benicar) 20mg PO qd

Hyperlipidemia:

• Continue Atorvastatin (Lipitor) 40mg PO qd

Osteoporosis:

• Continue Alendronate (Fosamax) 70mg PO qwk

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student

 

Initial DDx Based on CC:                                              Adjusted DDx After H&P:

PUD                                                                             Myocardial Infarction

GERD                                                                           Aortic Aneurysm

Gastritis/Gastroenteritis                                            GERD

Myocardial Infarction                                                 PUD

Aortic Aneurysm                                                         Pancreatitis

Pancreatitis

Cholecystitis

Appendicitis

Hepatitis

Medication side effect