Case Presentation
A. History
Mr. Gomez, a 50 year-old Hispanic male, presents to the Emergency Room with abdominal pain. You are paged by the nurse to assess him.
Upon arrival, you read in his file that Mr. Gomez has a past medical history of hypertension, history of an MI, and constipation. He currently presents with right upper-quadrant pain. For the past few weeks, he noticed that there is always pain "in his belly" after he eats a fatty meal. On his way home from a fast food place today, the sensation of really bad abdominal pain came back so he drove directly to the ER. In the ER, his temp is 98.6 F; pulse 92; and blood pressure is 150/100.
Past Medical History
Hypertension - poorly controlled
High cholesterol
Myocardial infarction in 2005
Depression
Constipation |
Family History
Came to US as child
No cancer, diabetes, no asthma, or pulmonary disease; no allergic conditions |
Medications
Lisinopril 40mg daily
Atenolol 50 mg daily
ASA 81 mg daily |
Social History
High school teacher
Married
3 Children and his mother lives with him
Occasional alcohol (1-2 beers/night)
No drugs, no cigarettes
Attends Hispanic church regularly |
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