(Answered) This week, complete the Aquifer case titled “Family Medicine 19: 39-year-old man with epigastric pain.”

(Answered) This week, complete the Aquifer case titled “Family Medicine 19: 39-year-old man with epigastric pain.”

(Answered) This week, complete the Aquifer case titled “Family Medicine 19: 39-year-old man with epigastric pain.” 150 150 Prisc

This week, complete the Aquifer case titled “Family Medicine 19: 39-year-old man with epigastric pain.”

The patient is 39 years old male, Mr Rodriguez, patient reports to clinic with epi gastric pain. Patient is of a latino origin (Dominican republic) who recently came to the United States. Patient has been experiencing upper epigastric pain which he describes as burning. Patient has noted that pain get worse when he consumes food and sometimes eating ameliorates the pain. The patient consumes ibuprofen to alleviate his pain as well as the use of herbal supplements which was noted not to be efficient in solving his problems related to the pain. Patient Denies weight loss, fevers, chills, or night sweats. He has had no recent illnesses. Aside from a recent move to the US from the Dominican Republic, he has not travelled recently. Denies any dysphagia, regurgitation, nausea, vomiting, anorexia, early satiety, hematemesis, hematochezia, melena, diarrhea or constipation. Denies dysuria, hematuria, or change in frequency. Patient denies allergies to drugs or food. Patient states that he however drinks 4 beers a week and smokes which he recently stopped. Father had hypertension and mother has diabetes.

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?

Sample Answer

Mr Rodriguez History

Mr Rodriguez, a 39-year-old Hispanic male, presents to a clinic with epigastric painHe describes the pain as a burning sensation at the upper epigastric area of the abdomen. He had realized that the pain worsened after food consumption, and at times eating ameliorates. The pain symptoms had been present for a year and continued to get worse each day. The patient denies vomiting, nausea or diarrhoea. He claims to be taking ibuprofen for generalized pain and aches and consuming herbal supplements like herbal tea for the pain (Bouroubi et al., 2017). He has not undergone any form of surgery or had any chronic illness. His mother has diabetes, while his father suffered from hypertension.

Physical Examination and Diagnostic Tools to Be Used for Mr Rodriguez and Any

Information to Be Included

Mr Rodriguez physical examination should focus on the gastrointestinal system since abdominal pain may have many causes such as gall bladder, gastritis, or chronic appendix constipation. The gastrointestinal exam should involve auscultation and palpitations from all quadrants, discussion on eating habits, guaiac exam and a test for H. pylori should be recommended counting stool acidity test.

Additional information should have been included in the environmental factors contributing to Mr Rodriguez problem, I.e., lack of physical exercise, obesity or stress.

Differential Diagnoses for Mr Rodriguez, Final Diagnosis and How to Make

The Determination

One of the differential diagnoses for Mr Rodriguez is gastritis which is the irritation of gastric mucosa caused by irritants like alcohol medications or H. pylori bacteria. The second differential diagnosis is gastroesophageal reflux disease which is related to eating or gastrointestinal sphincters problems. Often a patient may report bloating, pain in the epigastric area and belching. The final differential diagnosis is peptic ulcer disease caused by chronic usage of nonsteroidal anti-inflammatory drugs. These differential diagnoses have similar symptoms as Mr Rodriguez; therefore can easily be misdiagnosed.  The final diagnosis is peptic ulcer disease due to the prolonged usage of ibuprofen, alcohol consumption, smoking and pain at the epigastric area followed by a burning sensation. Mr Rodriquez had also moved to the United States, which put him at risk of H. pylori transmitted through the orofecal route and is most common in poor sanitary conditions like in his original homeland, the Dominican Republic which is a possibility.

Care Plan for Mr Rodriquez, Patient Education and Follow-Up

Mr. Rodriguez may be given proton pump inhibitors like omeprazole daily, clarithromycin for 14 days and amoxicillin. In case he is H. pyloric positive then omeprazole will be the best option (Braga, et.al 2021). He will also stop taking ibuprofen since it irritates the stomach. In addition, he will be advised not to skip any meal to minimize levels of acidity and avoid spicy foods since they make his stomach worse (Li et al. 2020). A follow-up in 4 weeks will be recommended to check on his progress.