Passage / Scenario

0900:

Client reports, "I'm bloated and my stomach hurts."

History of prior illness:

Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1hr after eating a meal and pain is worsened by eating.

Past Medical History: osteoarthritis

Social History: recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco

Current Medications: Ibuprofen 800 mg three times daily PRN arthritis pain

General: client appears uncomfortable, diaphoretic head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale

Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness