History of Present Illness M.S. is 56

History of Present Illness M.S. is 56 years old Hispanic male who presents with complaints of a four-week history of gradually increasing upper abdominal pain. He describes the pain as “burning” in nature, localized to the epigastrium, and that previously it had been relieved by drinking milk or Mylanta. Pain is much worse now and milk or antacids do not provide any relief. He scores the pain as “7” on a scale of 1-10. The patient does not feel the pain radiating into his back and has not noticed any blood in his stools. He denies any nausea, vomiting, weight loss, shortness of breath, neurological symptoms, or chest pain with exercise. He maintains that his appetite is excellent. He has been taking 400 mg ibuprofen almost daily for knee pain for the last 18 months. He injured his right knee in a car accident 15 years ago. He also takes daily doses of 81 mg aspirin for his heart although this has not been prescribed. He does not take any other prescribed or OTC medications. The patient smokes 1 ½ packs of cigarettes every day and has done so far for 5 years since his wife passed away. He does not drink alcohol or use illegal drugs. The patient is allergic to meperidine and develops a skin rash when he is treated with it. He admits to feeling “stressed out” as he recently lost his job of 20 years as an insurance salesman and has had difficulty finding another. Furthermore, his unemployment compensation recently lapsed. M.S. has been feeling a bit tired lately. He was diagnosed with HTN (Stage 1 ) three years ago and has been managing his elevated BP with diet and regular workouts at the gym. His younger brother also has HTN and both his parents suffered AMIs at a young age. M.S. has a history of gallstone and laparoscopic removal of his gall bladder six years ago. He also has a history of migraine headaches. Analyses the pathophysiologic process presented in this case Include a brief introduction of the anatomy or physiology of the system the disease process is affecting. Include a brief discussion of the pathophysiology of the disease, including physical exam presentations, lab data variances, and etiology and risk factors. Include a detailed presentation of the case study, including the following: The chief complaint of the patient The ROS of the patient Physical exam and lab data findings Differential diagnoses discussion The treatment plan, potential complications, and progression/outcome review

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