Respond to Jessica
Discuss Mr. Rodriquez’s history that would be pertinent to his gastrointestinal problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
Chief Complaint: 39 year old male latino patient from Dominican Republic presenting with epigastric pain that has worsened in the last couple months
HPI: Recently moved from Dominican Republic to the US. Abdominal pain for about a year and occurs a few times a week but has recently progressed to everyday in the epigastric region. Patient takes ibuprofen and herbal teas for pain but no relief achieved
PMH: Denies any medical or surgical history
Social: Patient quit smoking 6 months ago and drinks 3-4 beers a week
Family: Father with high BP, mother with diabetes
Vital Signs: T 36.9 degrees C, HR 78 beats/min, RR 16/min, BP 123/72 mm Hg, BMI 24.8
General: Well -appearing, middle aged man
HEENT: Sclera anicteric, no conjunctival pallor, oropharynx without lesion or significant dental abnormality.
Neck: Supple, no mass, lymphadenopathy, or thyromegaly.
Cardiovascular: Regular heart rate and rhythm, S1, S2, no murmurs, rubs, or gallops.
Respiratory: Bilaterally clear to auscultation and percussion without wheezes, rales or rhonchi.
Abdominal: Symmetric appearance without scars or ecchymosis. Normoactive bowel sounds heard in four quadrants. Soft, nondistended, with minimal epigastric tenderness on deep palpation without rebound tenderness or guarding, no hepatosplenomegaly, and no herniae or masses.
Skin: Tanned; no jaundice, several tattoos on his upper extremities, no suspicious lesions.
Extremities: Warm and well-perfused, no cyanosis, clubbing or edema.
Describe the physical exam and diagnostic tools to be used for Mr. Rodriguez. Are there any additional you would have liked to be included that were not?
