PRACTICE CASE 2
Chart Information
Chief complaint: A 31-year-old man comes to the clinic with chest and stomach pain.
Vital signs: T: 98.6 F (37 C), BP: 130/85 mm Hg, HR: 108/min, RR: 16/min
History
For approximately a year, this patient has suffered a burning, epigastric pain (4/10). The pain is located in the center of his stomach, occasionally in his lower chest, and seems to spread through to his back. The pain occasionally wakes the patient at night, although it does not seem to be associated with any constitutional symptoms. He has not suffered any night sweats, fevers, chills, or significant weight loss, nor has he had any recent diaphoresis, shortness of breath, nausea, or vomiting. He does, however, occasionally suffer from a burning sensation and foul taste in his throat. Recently, the pain has become more frequent and more painful, and the patient has had some episodes of dark stools, although he has never noticed any blood in his stool. Eating seems to help with the pain, as do over-the-counter antacids. The pain does not appear to be related to exertion. Aside from over-the-counter antacids, the patient takes no medications, prescriptions, or otherwise, and specifically denies taking any nonsteroidal anti-inflammatory medications. He is single and works as an investment banker. He has an erratic diet, eating when he can (usually fast food), and admits to a 20-pack-year history of tobacco and a near-daily consumption of one to two gin and tonics to help him relax from the stresses of work. He denies using illicit drugs. Occasionally, the alcohol may worsen his symptoms. Aside from his current symptoms, which he has not suffered before this year, he has no other medical problems and is unaware of any medical problems in his family. He specifically denies any history of diabetes, heart disease, or elevated lipid levels in himself or close family members.
Physical Examination
His chest is clear to auscultation bilaterally, and tactile fremitus is within normal limits. His cardiac exam demonstrates normal sounds, rate, and rhythm, without any murmurs, rubs, or peripheral edema. His jugular venous pressure is about 7 cm H20. On abdominal exam, his liver and spleen are not enlarged. He has normal active bowel sounds, and his abdomen is tympanic to percussion in all four quadrants. He is mildly tender to palpation in the mid-epigastric area, but displays no rebound tenderness or guarding. He has a negative Murphy sign. Of note, the patient states he normally is much darker skinned than he is currently.
