Apply information from the Aquifer Case Study to answer the following discussion questions:
Discuss the 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.
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?
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?
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?
Family Medicine 19: 39-year-old man with epigastric pain.
1. 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. Rodriguez is 39 years old Hispanic male who presents for worsening abdominal pain. The patient describes the pain as a burning sensation in the epigastric area of the abdomen. The pain has been present for 1 year occurring 3-4 times a week, now worsened with daily symptoms. Pain does not change with eating, no nausea, vomiting or diarrhea reported. The patient has a primary history of smoking quit 6 months ago, drinks 3-4 beers weekly but denies any drug use. The patient states he takes ibuprofen daily for generalized aches and pains, and drinks herbal tea “Yerba Buena.” The patient is otherwise a healthy male with no past surgical history or chronic medical problems. Family history of paternal hypertension and maternal diabetes.
2. Describe the physical exam and diagnostic tools to be used for Ms. Rodriguez, Are there any additional you would have like to be included that were not?
Physical exam for Mr. Rodriguez should include a complete examination with a focus on the gastrointestinal system: abdominal pain may have many sources such as, gastritis, gall bladder or appendix chronic constipation, stress, dietary or cardiac-related a thorough history is important. Gastrointestinal examination such include palpation and auscultation in all quadrants, discussing eating and bathroom habits and guaiac stool examination. Also test for H. Pylori will be recommended. (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017).
3. Please list 3 different diagnoses for Mr. Rodriquez and explain why you choose them. What was your final diagnosis and how did you make the determination?
Differential diagnoses for Mr. Rodriguez are 1. Gastritis: irritation of the gastric mucosa caused by irritants such as medications, alcohol or H. Pylori bacteria. 2. Gastroesophageal reflux disease (GERD): “heartburn” and regurgitation of acidic stomach contents, which may be related to problems with the gastrointestinal sphincters or eating problems. Often patients may report pain in the epigastric area, bloating, feeling of fullness bloating and belching. and 3. Peptic ulcer diseases (PUD): this refers to ulceration of the gastric and duodenal mucosa often caused by chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) or H. Pylori bacteria. (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017). My final diagnosis is peptic ulcer disease, because of the chronic use of ibuprofen, alcohol consumption, history of smoking and the location of the pain in the epigastric area with a burning sensation present. (Drini, 2017). Aso, Mr. Rodriquez recently immigrated to the United States from the Dominican Republic(DR) placing him at a higher risk for H. Pyloric. H pylori are transmitted via an orofecal route (Buttaro et al., 2017) and given the poor sanitary conditions in the DR this a real possibility.
4. What plan of care will Mr. Rodriquez be given at this visit, include drug therapy and treatment; what is the patient education and follow-up?
Mr. Rodriguez will be given a prescription for a proton pump inhibitor such as omeprazole to be taken once daily before food, amoxicillin, and clarithromycin for 14 days. if he as a postive H Pylori test otherwise omeprazole will be the treatment of choice (Woo, 2016). Besides, he will be advised to stop taking ibuprofen since this can be irritating to his stomach and take Tylenol instead. Also, he will be advised to not eat spicy food since this can make his symptoms worse, not skip meals and have a snack in between meals to decrease stomach acids. Mr. Rodriguez will be advised to follow-up in six weeks to check on his progress.
Buttaro, T. M., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary Care: A collaborative practice (5th ed.).
Drini, M. (2017,). Peptic ulcer disease and non-steroidal anti-inflammatory drugs. Australian Prescriber, 40(3), 91-93. https://doi.org/ 10.18773/austprescr.2017.037
Woo, T. M. (2016). Pharmacotherapeutics for advanced practice nurse prescribers (4th ed.). Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780803676374/cfi/6/6!/4/2/2/2/2@0:0
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