Abdominal Pain Case Study

Abdominal Pain Case Study

Chief Complaint

Abdominal pain.



History

Patient is a 63–year–old right–hand white male who states that since April when he was in rehab for his left total knee replacement he has been having pain along his abdomen. He describes this as a band of numbness and dysesthesia. He outlines a strip involving T9–T11. He states this is mostly on the right. It does extend past the midline a little to the left, but is not significantly disturbing on the left. He gets spontaneous stabbing pain, tingling and dysesthesias in that area. Also, he is extremely sensitive to touch, more so anteriorly and laterally than posteriorly. Posteriorly, it goes to the mid–axillary line on the right and again it just extends past the midline to the left. He states that he did have a fall 12 years ago with a coccyx fracture. He has not had any recent injuries or recent x–rays. He does have some numbness and tingling in his feet, but it is not significant. He did not notice any vesicular rash on his torso at any time since the onset of these symptoms. He is unable to give any further history. ... Show more content on Helpwriting.net ...The rest of review of systems were reviewed and are negative.



Social History

He is a smoker. He is divorced. Retired from the shipyard.



Family History

Abdominal aortic aneurysm, CHF.



Past Medical History

Coronary artery disease with a stent, which thrombosed and was re–stented, hypertension, hypercholesterolemia, diabetes type 2, poorly controlled, tubular adenoma of the colon, low B12 noncompliant with B12 replacement, adrenal mass, status post cholecystectomy, polycythemia due to smoking, left total knee replacement.



Allergies

Penicillin.



Medications

Plavix 75 mg, aspirin 81 mg, simvastatin 40 mg, insulin, metformin 1000 milligrams b.i.d., Trulicity shots every week, ramipril 10 mg.



Examination

Constitutional

Weight 231 pounds. Height: 5' 8". Respirations 12. Pulse

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