Respond to Jessica
• Discuss Mr. Rodriquez’s history that would be pertinent to his gastrointestinal problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
Chief Complaint: 39 year old male latino patient from Dominican Republic presenting with epigastric pain that has worsened in the last couple months
HPI: Recently moved from Dominican Republic to the US. Abdominal pain for about a year and occurs a few times a week but has recently progressed to everyday in the epigastric region. Patient takes ibuprofen and herbal teas for pain but no relief achieved
PMH: Denies any medical or surgical history
Social: Patient quit smoking 6 months ago and drinks 3-4 beers a week
Family: Father with high BP, mother with diabetes
Vital Signs: T 36.9 degrees C, HR 78 beats/min, RR 16/min, BP 123/72 mm Hg, BMI 24.8
General: Well -appearing, middle aged man
HEENT: Sclera anicteric, no conjunctival pallor, oropharynx without lesion or significant dental abnormality.
Neck: Supple, no mass, lymphadenopathy, or thyromegaly.
Cardiovascular: Regular heart rate and rhythm, S1, S2, no murmurs, rubs, or gallops.
Respiratory: Bilaterally clear to auscultation and percussion without wheezes, rales or rhonchi.
Abdominal: Symmetric appearance without scars or ecchymosis. Normoactive bowel sounds heard in four quadrants. Soft, nondistended, with minimal epigastric tenderness on deep palpation without rebound tenderness or guarding, no hepatosplenomegaly, and no herniae or masses.
Skin: Tanned; no jaundice, several tattoos on his upper extremities, no suspicious lesions.
Extremities: Warm and well-perfused, no cyanosis, clubbing or edema.
• Describe the physical exam and diagnostic tools to be used for Mr. Rodriguez. Are there any additional you would have liked to be included that were not?
The physical exam should include a comprehensive assessment of all systems. It is important to do so because we are unsure as to when he last visited a doctor since he moved from a different country. He does not have health insurance nor does he believe doctors, therefore good rapport with this patient is a must. A focused assessment on the GI system will be crucial, such as inspection, auscultation, palpation and percussion (Ferguson, 2010). Obtaining the vital signs is important to have a baseline. Some supplemental tests I would have liked to include are a CBC, an amylase and lipase, as well as liver function panel in order to have a better idea of the patient’s GI system (Cartwright & Knudson, 2008). In order to rule out anything cardiac related, I would have ordered an EKG and cardiac enzymes.
• list 3 differential diagnoses for Mr. Rodriguez and explain why you chose them. What was your final diagnosis and how did you make the determination?
The first diagnosis is Peptic Ulcer Disease (PUD). This is usually caused by an H. pylori infection and the use of NSAIDs. The typical symptoms are epigastric pain that resides between the breastbone and belly button, which can be relieved by food or antacids and may even cause awakening at night time. On physical assessment, the patient may feel pain upon palpation and lead to epigastric tenderness (Ramakrishnan & Salinas, 2017). The pain can get worse or improve with eating food. Mr. Rodriguez seems to have these symptoms and therefore this diagnosis is a high possibility, especially since he does take NSAIDs.
A second diagnosis is GERD, which can present itself with mild epigastric pain and usually these symptoms can worsen after meals. This pain is often classified as a burning pain and may come from acidic regurgitation (Heidelbaugh, 2021). The main symptom of GERD is heartburn which is described as a fiery feeling and as a tasting sour or bitter liquid from the stomach to the throat and can worsen after meals (GERD, 2021). This is a possible diagnosis, even though less likely than the PUD. However, it is known from the case scenario that this diagnosis is not correct as the patient found no improvement after treatment with PPI.
Lastly, the last diagnosis for this patient is gastritis, which is an inflammation of the stomach lining, and causes sharp epigastric pain. It may worsen or improve with eating food and could be caused by chronic infections such as H. pylori, or acute infections such as enterovirus. Alcohol and medications could also be responsible for this disease (Heidelbaugh, 2021) . Symptoms can vary and include black, tarry stools, nausea and vomiting, loss of appetite and bloating, which seems to be different from what the patient is experiencing.
• What plan of care will Mr. Rodriquez be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
The plan of care for this patient will be to start the triple therapy for 10-14 days. This includes a proton-pump inhibitor (esomeprazole once daily), amoxicillin 1g twice daily, and clarithromycin 500mg twice daily (Heidelbaugh, 2021). Because H. pylori is a bacteria, the PPI should be combined with antibiotics. The urea breath test is also a possibility for detection and eradication of the bacteria; however, Mr. Rodriguez will have to stop his PPI and antibiotics for at least 2 weeks prior to taking the test. It will also be important to teach the patient about the possible side effects of those medications such as diarrhea, nausea, abdominal pain as well as altered taste (Heidelbaugh, 2021). The patient should make a follow up appointment if this treatment does not solve his condition.
References
Cartwright, S., & Knudson, M. (2008). Evaluation of acute abdominal pain in adults. American Family Physician, 77(7), 971-978.
Ferguson, C. (2010). Clinical methods: The history, physical, and laboratory examinations. 3rd edition. Clinical Methods. Retrieved July 26, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK420/
Gastroesophageal reflux disease (GERD). (2021). Johns Hopkins Medicine. Retrieved July 26, 2021, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/gastroesophageal-reflux-disease-gerd
Heidelbaugh, J. (2021). Family Medicine 19: 39-year-old male with epigastric pain. Aquifer. https://southu-nur.meduapp.com/document_set_document_relations/30239
Ramakrishnan, K., & Salinas, R. (2017). Peptic ulcer disease. American Family Physician, 76(7), 1005-1012.
Respond to Yudy
