Question

Write a PES statement for this individual

42 y/o, acute onset epigastric abdominal pain associated w/ nausea and bilious vomiting, poor appetite, 20lb unintentional wt loss over past 3 months, gastroporesis dx

Answer 1

Here is a possible PES (Problem, Etiology, Signs/Symptoms) statement for this patient:

Problem: A 42 year old male with acute epigastric abdominal pain, nausea/vomiting, poor appetite, and 20lb unintentional weight loss over 3 months.

Etiology: Unknown gastrointestinal etiology, possibly peptic ulcer disease or gastric malignancy.

Signs and Symptoms:

•Acute onset epigastric abdominal pain

•Nausea and bilious vomiting

•Poor appetite and 20lb unintentional weight loss over past 3 months

•Previous diagnosis of gastroparesis 3 months ago, though symptoms have worsened.

Additional Information Needed:

•Medical history including any past surgeries, medications, or gastrointestinal issues.

•Complete blood count, comprehensive metabolic panel, liver function tests, and abdominal imaging (CT, UGI, endoscopy).

•Stool for occult blood.

•Helicobacter pylori testing.

Differential Diagnosis:

•Peptic ulcer disease

•Gastric malignancy (adenocarcinoma)

•Gastroesophageal reflux disease with severe complications

•Chronic pancreatitis

•Helicobacter pylori infection

•Ulcerogenic medications (NSAIDs)

Treatment will depend on the underlying diagnosis and may include:

•Medications (antacids, H2 blockers, antibiotics)

•Lifestyle modifications (diet changes, smoking cessation)

•Surgery (gastrectomy, vagotomy) in severe cases

Step-by-step explanation: