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Mr. Rodriquez is a 37-year-old male who is being for worsening upper abdominal pain that has became more persistent. Mr. Rodriquez reports that he quit smoking, consumes alcohol, and ibuprofen on a regular basis.
Mr. Rodriquez is a recent immigrant from the Dominican Republic who only speaks Spanish. Mr. Rodriquez reports being underinsured and not having money to seek medical care.
Mr. Rodriquez reports no chronic medical conditions, no hospitalizations, and no past surgeries. Mr. Rodriquez’s father has a history of high blood pressure, and his mother has a history of diabetes.
Temperature is 98.5 F, pulse 78 beats/minute, regular, resp 16 breaths/minute, BP 123/72 mmHg, BMI 24.8 kg/m2. HEENT: NC/AT, PERRLA, TM intact, negative for inflammation, negative for congestion, oropharynx WNL, no erythema. Cardiovascular HR normal rate and rhythm, negative for murmurs, rubs, or gallops, S1, S2. Respiration normal, clear, no wheezes, rales, or rhonchi. Abdominal normal bowel sounds in all four quadrants, soft non-tender, negative for hernia, or mass, epigastric tenderness.
Diagnostic tools include testing for H. pylori, endoscopy, and x-ray of the upper digestive system.
• 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?
Gastritis: Gastritis causes sharp epigastric pain. Food can increase or decrease pain. Can be caused by alcohol and medication consumption.
Gastroesophageal: Gastroesophageal causes epigastric pain that may worsen after meals. Gastroesophageal usually includes nausea, vomiting, hematochezia, and melena.
Peptic Ulcer Disease: Peptic ulcer disease causes epigastric pain that may improve with meals. NSAIDs can cause peptic ulcer disease.
The final diagnosis would be gastritis. The patient states that he is having abdominal pain. Food sometimes improves the pain and sometimes worsens the pain. The patient reports regular alcohol and ibuprofen consumption. Gastritis can be caused by alcohol and NSAID use which the patient reports regular use of. Food can improve pain or worsen the pain. The patient reported that sometimes food improves the pain and sometimes food worsens the pain.
Treatment includes lifestyle modifications such as eating smaller meals, avoiding foods that irritate it, avoiding alcohol, and stop taking NSAIDs. In acute causes, lifestyle modifications may be enough. In more chronic cases medication may be used. Medications include antibiotics to treat H.pylori if present, proton pump inhibitors, acid blockers, and antacids.
References:
Mayo Clinic. (n.d.). Gastritis. https://www.mayoclinic.org/diseases-conditions/gastritis/diagnosis-treatment/drc-20355813
Heidelbaugh, J. (n.d.). Family Medicine 19: 39-year-old male with epigastric pain. https://southu-nur.meduapp.com/document_set_document_relations/30239?section_uid=root
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Gastrointestinal Disorder.
The condition should be treated as soon as it is realized through laboratory tests by medical practitioners. The condition grows in stages until it gets to the most critical condition which is always characterized by abdominal pain as well as other symptoms when left untreated.
According to Mr. Rodriguez, condition, his HPI clearly shows that he does not have any history of present illness, but he recently traveled from Dominica republic to America. The patient has no history of problem with the digestive system but has suffered stomach pain for at least a year. The chief complaint Mr. Rodriguez have during his clinic visit is associated with abdominal pains that radiates to the epigastric area. He stated denies any hospitalization for stomach problems or having any operations. He also explains over the last year the pain did subside but recently has become constant. This is a major indication that the symptoms are the result of a condition that is chronic and has progressively gotten worst. Mr. Rodriguez social history consist of smoking but recently quit, use of NSAIDS for soreness and herbal teas. His father suffers from high blood pressure and his mother has diagnosis of diabetes. He denies and family history of gastrointestinal disorders.
For the medical examination for the gastrointestinal disorder, the patient must undergo auscultation which involves listening to all four quadrants, liver for bruits, and rubs as well as the abdominal walls for the bowel sounds (Couce, 2020). The provider may also ask to conduct a series imaging tests on the patient such as upper endoscopy, Lower (GI) Gastrointestinal series, Colonoscopy, and lab work that consist of CBC with differential.
In the clinic, there was three suspected diagnosis which included the gastrointestinal disorder, gastro esophageal reflux disease (GERD), Gastritis, and H. Pylori(ulcers). These conditions share some common symptoms and thus proper examination must be conducted to ascertain the actual disease which a patient is suffering from (Saps, 2017). After thorough laboratory tests, we were able to identify that the patient was suffering from gastrointestinal disorder due to the presence of an infection of the digestive systems, H. Pylori which was found right of the esophagus to the stomach into the duodenum. Gastrointestinal disorder such as H. Pylori (ulcers) is quite common especially in undeveloped countries like the country of Dominican Republic. This GI disorder is known to be asymptomatic for years before detection. The lab work for Mr. Rodriquez was positive for H. Pylori which confirmed the diagnosis.
For this clinical visit, Mr. Rodriguez will be put on medication which will help improve his condition which may consist of a combination. The medicines for the treatment of this condition may be acquired over the counter and thus making it easily accessible to Mr. Rodriguez would be started on the standard dose PPI two times a day for acid reflux/ stomach discomfort, Amoxicillin 1 gram once a day, Clarithromycin 500 mg two times a day, for ten to fourteen days(Zammit, 2018). Patient will be educated on specific foods to refrain from that aggravate the GI system such as spicey food and caffeinated drinks or alcohol. Although certain foods and beverages can cause stomach upset, there is no good evidence that they cause or worsen ulcers. Still, eating a healthy diet with plenty of fruits, vegetables, and fiber may decrease the risk of ulcers. Patient will also be educated on the use of NSAIDs and the contraindication of taking them with his diagnosis. Patient should follow-up in 2 weeks to assess how treatment has help and also follow-up before then if symptoms have worsened.
