Based on the case study provided, respond to the following questions: Identify a
ID: 305204 • Letter: B
Question
Based on the case study provided, respond to the following questions:
Identify and differentiate the symptoms from the signs in this patient.
Did you find any remarkable detail in the personal and social history of our patient that can help to make the diagnosis?
What results do you expect to find in the tests ordered?
What are some future complications the patient is at risk of developing?
Case Study
Personal Information
Name: Mr. Christopher Franklin
Age: 60 years old
Gender: Male
Description
Mr. Franklin is a 60-year-old patient with a history of a thrombotic cerebrovascular accident two years ago. After the stroke he started with seizure attacks. He has been suffering from hypertension for the last ten years and ulcerative colitis since last year. He currently takes lisinopril, hydrochlorothiazide, aspirin, carbamazepine, and a low dose of prednisone.
Mr. Franklin has been suffering from epigastric pain, sensation of fullness, and occasional nausea for the last six months. This time, he was brought to the ER because, while he was talking to his son, he had a dizzy spell and fell to the floor. He is conscious and is complaining of severe epigastric pain. He began with mild abdominal pain two days after he started taking a new cycle of prednisone for his colitis, around seven days ago. The pain increases when he eats or drinks something. He is also complaining of suffering from pyrosis, malaise, and dizziness, and he has noticed that his feces are dark.
The patient was a heavy alcohol drinker until he had the stroke. He is a cigarette smoker since he was 20 years old. His mother suffered from Alzheimer’s disease and died of colon cancer, and his father died of cirrhosis of the liver.
On physical examination we found:
Remarkable Signs on Physical Exam by Regions
Abdomen: Pain on palpation on epigastric region
SOMA: Right hemiplegia and hyperreflexia
Remarkable Signs on Physical Exam by Systems
Integumentary system: Pallor, diaphoresis, coldness
Cardiovascular system: Tachycardia. Blood pressure 70/50 mmHg. Radial pulse 110.
Digestive system: Tenderness of epigastric region. Rectal exam showed melena.
Neurologic system: The patient is conscious and well oriented to time, place, and person. Right hemiplegia and hyperreflexia.
Lab Tests
Complete blood count (CBC)
Metabolic panel
Lipid panel
Abdominal CT scan
Esophagogastroduodenoscopy
Main Diagnosis
Upper digestive bleeding due to drug-induced gastritis
Hypovolemic shock
Acute anemia
Other Diagnoses
Stabilized thrombotic cerebrovascular accident
Epilepsy
Essential hypertension
Ulcerative colitis
Explanation / Answer
Some of the signs and symptoms which can be differentiated from signs and symptoms are
Pain on epigastric region indicates problems with gastric region (gastritis)
Pallor, diaphoresis, coldness of the skin, tachycardia indicates hypovolemic shock
Dizziness indicates low BP and probably a decrease of blood to brain, hypovolemic shock,anemia making him unconscious for a while
Shock is because of blood loss
Malena indicates bleeding in the gastrointestinal tract.
His personal and social history like smoking , alcohol , family medical conditions his age , medications taken all helps in the identification of diagnosis.
Laboratory value of
CBC :low HB level
Metabolic panel: changes in muscles of kidney,liver heart muscles are known.Along with this there will be changes in creatinine level ( increased) due to hypovolemic shock, calcium and electrolyte imbalance causing dizziness, protein levels indicates changes of brain tissue.
Lipid indicates changes in cholesterol levels
Abdominal CT helps to identify gastritis
Esophagogastroduodenoscoy helps to identify the site of bleeding
Complications:
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