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

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

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.

Mr. Rodriquez is a 39-year-old Latino immigrant who recently came from the Dominican Republic with progressively worsening pain in his epigastric area. He does not have any vomiting, vomiting blood, passing of any blood, dark or tarry stools, and is not associated with consumption of meals. He denies any serious personal medical and surgical history. He recently quit smoking and drinks approximately 3 to 4 beers a week, takes ibuprofen daily, and drinks herbal teas for the abdominal pain, which has not solved the problem.

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?

Because several different factors can cause abdominal pain, it is important to conduct a physical assessment on the patient. This should include all the body systems followed up with a focused assessment on the gastrointestinal, cardiovascular, and respiratory systems. It is important to note that the head-to-toe assessment is within the normal limits since the patient denies recent sickness or symptoms in all systems except the abdominal pain which epigastric he has with minimal epigastric tenderness on deep palpation without rebound tenderness or guarding, no hepatosplenomegaly, and no hernia or masses. In addition, his vital signs are stable. Testing for H.Pylori may have been performed on the initial appointment, allowing for a more thorough diagnostic diagnosis to be provided.
Please 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 three-differential diagnosis for Mr. Rodriguez includes gastroesophageal-reflux disease (GERD), peptic ulcer disease (PUD), and gastritis. GERD symptoms include epigastric pain, which is usually worse after meals. Passing bloody, dark, or tarry stools do not usually accompany GERD (Silvia et al., 2018). The pain is usually described and burning and is usually located in the substernal area instead of the epigastric area. Peptic ulcer disease is a pain in the epigastric area that usually improves with meals. PUD is associated with NSAID use. Vomiting blood is not usually a symptom of PUD (Ozbey & Hanafiah, 2017). Gastritis is caused by the inflammation or irritation of the stomach lining accompanied by a sharp pain in the epigastric area. It is usually worse after meals (Ozbey & Hanafiah, 2017). It is usually caused by the infection of H. pylori or other viruses or by chemical irritants to the stomach, including alcohol and NSAIDs. The final diagnosis was gastritis caused by H. pylori. A proton pump inhibitor was prescribed to Mr. Rodriguez, as well as the cessation of NSAIDs. This did not resolve his symptoms, so a test was done to diagnose H. pylori infection and a complete blood count to rule out a GI bleed.
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?
On the first visit, Mr. Rodriguez was given a proton pump inhibitor, omeprazole, and lifestyle modifications. This did not relieve his symptoms and forced him to return for a follow-up visit. When he returned, a test for H. pylori was conducted and came out positive. He was then prescribed “triple therapy” to treat the H. pylori infection. This included 14 days’ worth of proton pump inhibitor, omeprazole, twice daily; the antibiotic, amoxicillin 1 gram, twice daily, and the antibiotic, clarithromycin 500 milligrams, twice daily. Mr. Rodriguez returns to say that the treatment worked temporarily, so Levofloxacin is added to his treatment with relieves his symptoms. The symptoms may return, however, so he is referred to help obtain health insurance, so he does not have to wait for treatment again. He should be educated in his language on the side effects of the medication and the importance of taking it on schedule (Blevins, 2018). He should also be educated to return to the clinic if he begins vomiting blood or passing blood or if his symptoms worsen more.
References
Blevins, S. (2018). The art of patient education. Medsurg Nursing, 27(6), 401.
Chey, W. D., Leontiadis, G. I., Howden, C. W., & Moss, S. F. (2017). ACG clinical guideline:
treatment of Helicobacter pylori infection. The American journal of gastroenterology,
112(2), 212. doi: 10.1038/ajg.2016.563
Ozbey, G., & Hanafiah, A. (2017). Epidemiology, Diagnosis, and Risk Factors of Helicobacter
pylori Infection in Children. Euroasian Journal of Hepato-Gastroenterology, 7(1),
34–39. http://doi.org/10.5005/jp-journals-10018-1208
Silvia, C., Serena, S., Chiara, M., Alberto, B., Antonio, N., Gioacchino, L., … & Francesco, D. M. (2018). Diagnosis of GERD in typical and atypical manifestations. Acta Bio Medica: Atenei Parmensis, 89(Suppl 8), 33.

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