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Gastrointestinal Case Study
Henry, a 58 y/o male, recently reports waking up in the middle of the night with burning abdominal pain. Symptoms occur several nights a week with occasional discomfort in the middle of the afternoon. A bland diet or drinking milk do seem to help and spicy foods aggregate the symptoms.
PMH: non-contributory
SH: Works in a grocery store, divorced, non-smoker, drinks 1-2 beers/day
Allergies: none
Meds: 1 325mg ASA daily for cardiovascular prevention
ROS:
Constitutional: Decrease appetite and 5% weight loss; denies feverENT: Denies sore throat or drainageLungs: Occasional dry cough at nightHeart: Mid sternum chest burning intermittentlyAbdomen: Epigastric burning and tenderness, denies constipation or diarrhea
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