Clinical Diagnosis

Mr. B is 65 year old AA male arrived at the ED with his wife by his side. Wife states, “he couldn’t even eat his favorite meal Cajun jambalaya”. In between moans the patient is able to state he has a history of type 1 diabetes, hypertension, hyperlipidemia and that he had “stents put in his heart a little over year ago.” The patients informs the ED nurse that the pain is in his stomach, chest and he feels full, even though he hasn’t eaten today. The nurse does vital signs and Blood pressure is 168/108, Heart rate is 102, Respiration 22, SpO2 96%, Temperature 99. Mr. B’s wife has a list of the medications he is taking. The ED nurse reconciles the medication list. The list included Novolin, Metoprolol, Lipitor, daily aspirin, multiple vitamin and daily Ibuprofen. The patient states his pain is a 12 out of 10 pain. The ED nurse finds an open broom in the ED and Mr. B is transported into the room. The ED nurse does a focus assessment and further findings are Mr. B is having burning in his chest and dark stools. HIs bowel sounds are hyperactive. Mr. B asks if he can have more Ibuprofen he has been taking it around the clock because that seem like the only thing that helps the pain some. Mr. B let the ED nurse know he has to vomit again and the chest, stomach pains are worse.

What are the contradiction that will help to determine what might be going on with Mr. B?

No results