Introduction:

George Hodges; 48 ♂

Initial impressions:

Tasked at 19:03 to a private home for a patient with severe abdominal pain

Patient lying in bed. Wife and son present.

Situation:

      Hx

Sudden onset of epigastric pain about 1 hour after eating. Has had similar episodes over last 6 months, but this is episode is much more severe. Has not seen doctor about the pain.

Background:

      PHx

Hypertension

      Med’n

Irbestatan, Atorvastatin

      Allergies

Penicillin

      Comm. Diseases

nil known

      Social Hx:

Live with wife. Normally works nights as a security guard

      Family Hx:

Mother & father both alive; father has heart disease

      Diet:

Tends to eat a lot of takeaway.

      Alcohol:

2 -3 beers each day. Sometimes has some spirits.

      Smoking:

Nil

Vital signs:

GCS         15

Pupils     L4+:R4+

HR           88 (weak  & regular)

Pulse       Normal

Rhythm   Sinus

BP           150/90

RR           24

SpO2      96%

Skin         Pale, sweaty & warm,

Cap Refill<2

BGL         8.7

Temp      37.2

Pain        Sharp, stabbing epigastric pain; sudden onset after dinner, 10/10

Secondary survey findings

Patient has had similar episodes of pain after eating for the last 3 months. Seems to be worse after eating chips or other fatty food, or drinking too much alcohol. Patient is rather obese.