CC:



CC: 62 yo male with abdominal pain

HPI: 62 yo male presents to ED with c/o severe abdominal pain. He has had “gnawing” epigastric pain for several weeks, slightly improved with food. It has been getting more severe, esp in past 3 days. He was actually going to go to his clinic to get checked out several days ago, but b/c he could not get a ride, decided to wait until the VA bus went to Minneapolis (this is why he is coming in today). En route to the VA, the pain worsened (now rated 8/10). Pain was initially primarily in the epigastrium, but now seems more diffuse. No radiation.

Has been taking 600-900 mg of ibuprofen at least 3 times daily for chronic low back pain x one month.

ROS:

+

Nausea

Anorexia

Weight loss over past month.

Mild lightheadedness

-

Fevers, chills, sweats

Cough, dyspnea

Chest pain

Emesis, diarrhea, melena, BRBRP

Urinary sx

PMH:

Chronic low back pain

COPD

HTN

MEDS: (All: NKDA)

HCT-Z

Albuterol mdi prn

ibuprofen

SOC HX:

Lives outside of Redwing MN

Works as a farmer

Smokes 1ppd x35 yrs

Rare etoh (1-2 drinks/month)

No illicits

Sexually active with wife only

No recent travel, tick bites

Has daily contact with pigs and cows

FAM HX: unknown - adopted

PE:

Vitals: T95.6 P110 BP 113/63 RR 20 SpO2 98% RA

Gen: Elderly WM, laying still in bed, appears uncomfortable.

HEENT/Neck: PERRL, EOMI, sclera anicteric, OP clear, no LAN

CV: Tachycardic, RR, nl s1,s2 no m/r/g

Resp: CTA bilat. No wheezes/rales/rhonchi

Abd: nondistended, diminished BS, abd extremely tender to even light percussion and palpation. No rebound.

Rectal: nl rectal tone, minimal stool in rectal vault, no blood, patient c/o diffuse abd pain with exam.

Ext: no edema

Skin: no rashes or lesions

Neuro: A+Ox3

Labs (return after primary team leaves):

16.7 140 97 20

24.3>------< 312 -----I-----I-----< 185 Ca 9.4/Mg 2.1/Po4 4.7

N81, B8, L8 4.1 29 1.2

TB 0.9 INR 1.10

AP 83 Lactate 3.3 (upper normal 2.2)

ALT 22 UA sp 1.080, 30 prot, 3WBC

AST 23

On pt reassessment by the cross-covering intern, he is diaphorectic and obviously in severe pain. + rebound on exam (even slight movement of bed lead to pain).

Stat Flat and upright abd xray shows free air under the diaphragm

Emergent Surgery – perforated duodenal ulcer

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