Week 5 Discussion

docx

School

South University, Savannah *

*We aren’t endorsed by this school

Course

6020

Subject

Medicine

Date

Dec 6, 2023

Type

docx

Pages

Uploaded by ElderPheasant1655

1 Week 5 Discussion DOMAIN: HISTORY Mr. Rodriguez presents with burning in the epigastric area for more than a year, but more severe recently. He has had no nausea, vomiting, regurgitation, hematochezia, melena, or consistent association with meals. (Aquifer Family Medicine, 2022.) Mr. Rodriguez recently quit smoking, he occasionally consumes alcohol, three to four beers per week, and herbal teas and takes NSAIDs as frequently as every day. He has a family history of diabetes and high blood pressure but no known gastrointestinal diseases. One question that could have been asked and that wasn’t include what the pain rating is 1-10 as well as if the pain radiates to another spot. Digestive problems are the most common cause of abdominal pain, however discomfort or irregularities in any organ or part of the abdomen can cause pain that radiates throughout the entire area (Medical News, 2020). Another question that could have been asked is more specific about the patient’s diet as in how often he uses herbs, etc. The calming and relaxing effect on the muscles of yerba Buena tea can open the sphincter, leaking stomach acid unto the esophagus, worsening the GERD condition should that be the diagnosis. (Medical Health, 2020). DOMAIN: PHYSICAL EXAM A full head to toe assessment was completed to ensure all aspects of suspected diseases were found if any. In the abdominal portion of the exam, his abdomen was non-distended, symmetric appearance, with minimal epigastric tenderness on deep palpation without rebound tenderness or guarding, no hepatosplenomegaly, no hernia or masses. All other assessment findings were within defined limits.

2 DOMAIN: ASSESSMENT (Medical Diagnosis) GERD was being questioned as it is a difficult diagnosis. Additional diagnoses being investigated were gastritis due to epigastric pain and comfort as well as discomfort with food at different times depending on what type of food the patient was eating as well as peptic ulcer disease due to the pain sometimes being relieved by eating, again depending on what type of food was being eaten. (Nurselabs, 2022). DOMAIN: LABORATORY & DIAGNOSTIC TESTS A pH test would have been beneficial to have a better understanding of what was happening inside the body. Also, I would think an EGD needed to be completed to see if there were any visible signs of inflammation. Additional testing that would be beneficial includes a breath urea to screen for H. pylori, which is highly expected due to the medication regimens not being as effective as they should have been.

3 References Aquifer Family Medicine. (2022). Family Medicine 19: 39-year-old male with epigastric pain. https://southu-nur.meduapp.com/document_set_document_relations/30239 . Medical Health Guide. (2020). Yerba buena (Mentha arvensis) Herbal Medicine. Retrieved from http://www.medicalhealthguide.com/articles/yerbabuena.htm Medical News Today. (2020). 15 possible causes of abdominal pain. Retrieved from https://www.medicalnewstoday.com:https://www.medicalnewstoday.com/articles/318286 Nurselabs. (2022). 5 Peptic Ulcer Disease Nursing Care Plans. Retrieved from https://nurseslabs.com/peptic-ulcer-disease-nursing-care-plans/

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Week 5 Discussion

Related Documents