How to write an essay on Aquifer Case Study: Epigastric Pain.

How to write an essay on Aquifer Case Study: Epigastric Pain.

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.

Mr. Rodriguez is a 39-year-old male patient presenting to the clinic with complaints of epigastric pain. The patient reports that the pain started a year ago happening a few times a week but now hurts every day. He describes it as a burning sensation that is worsened by taking spicy foods. He regularly takes ibuprofen and herbal tea, Yerba Buena, for stomach pain but with no relief. The patient recently moved from the Dominican Republic to the US but has not traveled of late. He denies associated symptoms like weight loss, fever, chills, black-colored stool, and nausea or vomiting. Mr. Rodriguez denies a past medical history of gastrointestinal issues and chronic conditions. He reports to have quit smoking six months ago but drinks 3 to 4 beers a week. The family history reveals the presence of conditions like high blood pressure and diabetes that affect his father and mother respectively. He denies any history of surgery, hospitalization, and food or drug allergies.

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?

Mr. Rodriguez is a well-appearing patient whose physical examination reveals remarkable results. He appears to be anxious because of the abdominal pain. His vitals include temperature 98.5 Fahrenheit, pulse 78 b/m, respiratory rate 16b/m, blood pressure 123/72 mmHg, and BMI 24.8. The review of systems reveals normal results except for the gastrointestinal system where there is minimal epigastric tenderness on deep palpation. There is no rebound tenderness or guarding, no hepatosplenomegaly or masses. The diagnostic tools used for the patient include the performance of a digital rectal examination, guaiac-based fecal blood test, complete blood count, Urea breath test, H pylori fecal antigen test, and H pylori IgG serology. An additional test that I might consider is an upper endoscopy to rule out peptic ulcer disease and malignancy (Chey et al., 2017). Depending on the response to treatment, I might also consider doing an abdominal ultrasound to rule out a biliary disease that can manifest as persistent epigastric pain.

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?

Mr. Rodriguez presents with persistent epigastric pain for the past year with worsened symptoms for the past few weeks. The differential diagnosis for the patient includes gastroesophageal reflux disease (GERD), peptic ulcer disease, and gastritis. GERD is a condition in which the gastric contents leak back into the esophagus causing a burning sensation in the epigastric area and the throat. The symptoms worsen after meals and are more observed in the substernal rather than the epigastric area (McMahon et al., 2016). Gastritis involves the inflammation of the stomach lining that presents as sharp epigastric pain, abdominal tenderness, indigestion, and nausea/vomiting. The most probable diagnosis for the patient is peptic ulcer disease. Epigastric pain in PUD improves with meals and the use of NSAIDs only worsens the disease (McMahon et al., 2016). The diagnosis for PUD was made based on the presenting symptoms and H pylori IgG serology test alongside H pylori fecal antigen test performed.

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 Mr. Rodriguez at this point involves the initiation of H pylori treatment using the standard triple therapy. The therapy involves taking a proton pump inhibitor (PPI) twice daily, Amoxicillin 1g twice daily, and clarithromycin 500mg twice daily for a period of 10 to 14 days (Chey et al., 2017). The patient will be educated about the side effects of the regimen including headache, nausea, diarrhea, and unpleasant taste in the mouth. The patient will be encouraged to limit drinking, avoid smoking and the use of NSAIDs that might worsen his condition. The follow-up plan for the patient will be set after one month to evaluate the effectiveness of the therapy and to consider a possible change of medication if the symptoms persist.

 

References

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), 212–239. https://doi.org/10.1038/ajg.2016.563

McMahon, B. J., Bruce, M. G., Koch, A., Goodman, K. J., Tsukanov, V., Mulvad, G., Borresen, M. L., Sacco, F., Barrett, D., Westby, S., & Parkinson, A. J. (2016). The diagnosis and treatment of Helicobacter pylori infection in Arctic regions with a high prevalence of infection: Expert commentary. Epidemiology and Infection, 144(2), 225–233. https://doi.org/10.1017/S0950268815001181

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