Problem refinement

The patient points to an area in the upper central (epigastric) area of the abdomen. Further questioning reveals he is in some discomfort but hasn’t really experienced any other symptoms. The pain has been present now for a few hours and seems to be constant. He cannot recall anything that has triggered his symptoms.

With this additional information we can try and differentiate between the likely conditions. Location is not very helpful, as all three tend to show mid-upper abdominal symptoms. Likewise he hasn’t described other symptoms associated with the pain, which could have been helpful (e.g. heartburn is a strong predictor of GORD). Given the predominant symptom is constant pain, a differential diagnosis of peptic ulcer becomes more likely, which is further supported by his age.

To explore more fully his symptoms in relation to a possible ulcer, questions establishing if anything aggravates or relieves the pain and previous history of the presenting complaint should be asked. One would expect that this is not the first episode of GI pain and that symptoms would be worse when the stomach is empty if an ulcer is the cause.

Patrick has not experienced worsening pain with his current presenting symptoms but does say he has had this type of pain before. He cannot really recollect if it was made better or worse after eating food during these previous bouts. At this point the differential diagnosis is unclear and it could be simple dyspepsia or a possible ulcer.