6001-W3-D8

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Fazaia Degree College, M.R.F, Kamra, Attock *

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Nursing

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Nov 24, 2024

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Discuss Mr. Rodriguez’s history that would be pertinent to his gastrointestinal problem. Include the chief complaint, HPI, social, family, and past medical history that would be important to know. The patient is a 39-year-old male who has been living in the United States for two years. He is an undocumented worker and speaks/understands very little English so an interpreter is needed. He states that he has been experiencing intermittent pain (points to the epigastric area) for approximately a year but in recent times the pain has been daily (Heidelbaugh, n.d.). He states that it does not seem to be triggered by specific foods but did note that the pain was exacerbated when eating spicy foods. He denies any other possibly associated symptoms such as dysphagia, hematemesis, melena, fever, nausea, vomiting, unintentional weight loss, regurgitation, anorexia, diarrhea, or constipation (Heidelbaugh, n.d.). The patient denies any medical history, denies surgical history, and denies taking any prescription medication. The patient states that he takes ibuprofen almost daily for generalized body aches after working long days, and he endorses drinking a couple of beers a week. He used to smoke but stopped about six months ago and denies drug use. He denies any recent travel, domestic or international (Heidelbaugh, n.d.). When asked about his family history and whether anyone else in the family has this problem, he is unsure. He mentions that his father had hypertension and his mother had diabetes. The patient states that he drinks yerba Buena tea but states that it has been ineffective in addressing the issue (Heidelbaugh, n.d.). 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? The patient had a set of vital signs taken that were WNL. He appears well-nourished, welldeveloped, and anxious about his medical concerns. HEENT, cardiovascular, respiratory, neck, abdominal, integumentary, and musculoskeletal assessment findings were all WNL. The patient’s blood pressure and pulse point towards being hemodynamically stable. There are no signs of anemia such as brittle nails or cracked lips, no signs of malignancy such as weight loss or a palpable mass, and no signs of gallbladder involvement such as a positive Murphy’s sign (Heidelbaugh, n.d.). Please list three differential diagnoses for Mr. Rodriguez and explain why you chose them. What was your final diagnosis and how did you make that determination? Three differential diagnoses based on the history and presentation of the patient are gastritis, gastroesophageal reflux disease, and peptic ulcer disease. Gastritis was chosen because of some of the risk factors noted in the patient. Risk factors that can increase a person’s chances of getting gastritis include regular NSAID use and excessive alcohol intake (Mayo Clinic, 2022). Stress is also an important risk factor, and when appearing at the clinic the patient appeared stressed and anxious about his symptoms pointing to something more serious. Gastroesophageal reflux disease, also known as GERD, occurs when stomach contents rise back up through the esophagus and sometimes into the mouth. It causes a burning sensation in the upper chest and it is sometimes aggravated with spicy foods and alcohol intake (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], n.d.). Peptic ulcer disease (PUD) is a disruption of the inner lining of the stomach (ulcerations) due to stomach secretions or pepsin. It can involve different parts of the GI tract, and the pain is exacerbated after meals (Malik et al., 2023). There are several causes for PUD but the most common are NSAID use and H. pylori. The patient was initially treated empirically for GERD, gastritis, and PUD. Because the patient experienced no relief with the medication, and there were no other symptoms such as regurgitation, I began to suspect PUD secondary to H. pylori infection. The patient completed the H. pylori IgG assay and the results came back positive (Malik et al., 2023).

What plan of care will Mr. Rodriguez be given at this visit, including drug therapy and treatments; what is the patient education and follow-up? First and foremost, the patient should be applauded for quitting smoking. Smoking cessation decreases the risk of developing chronic illnesses such as cancer and COPD. Managing PUD can have positive outcomes for the patient with no long-term complications, but an interdisciplinary approach is a necessity. The registered nurse and pharmacist are integral in reinforcing patient teaching as well as monitoring drug regimen compliance (Malik et al., 2023). A medication combination that includes antibiotics and medications to decrease gastric secretions is indicated for the treatment of PUD. Medications that reduce gastric secretions include proton pump inhibitors (PPI) which are preferred over H2 receptor blockers due to their effectiveness. Because long-term use of PPI has been associated with an increased risk of bone fractures, calcium supplementation is also included (Malik et al., 2023). The preferred treatment for PUD is a “triple regimen” which includes two antibiotics such as clarithromycin and metronidazole for one to two weeks along with a PPI such as pantoprazole (Malik et al., 2023). If the first-line therapy is ineffective at clearing the infection, a “quadruple therapy” is implemented. Quadruple therapy consists of a PPI, metronidazole, tetracycline, and bismuth/subcitrate of the same timeframe (Heidelbaugh, n.d.). Mr. Rodriguez needs to be educated extensively on the importance of completing antibiotic therapy as prescribed, regardless of the symptoms improving. Patients diagnosed with PUD should be educated extensively on the potential harm surrounding NSAID use; if the patient has pain and it is not contraindicated due to other conditions or allergies, the patient should switch to acetaminophen (Malik et al., 2023). Dietary modifications include limiting alcohol intake, stopping tobacco use, and decreasing the amount of caffeine consumed. There is a correlation between obesity and PUD, so if the patient is overweight or obese, the patient needs to be instructed on the importance of weight loss to improve symptoms. The patient should follow up in two weeks once antibiotic therapy is complete to assess efficacy. Mr. Rodriguez needs to return to the clinic for any new or worsening symptoms. References: Heidelbaugh, J. (n.d.). Family medicine 19: 39-year-old male with epigastric pain. Aquifer. Retrieved November 6, 2023, from https://southunur.meduapp.com/document_set_document_relations/30239 Malik, T. F., Gnanapandithan, K., & Singh, K. (2023, June 5). Peptic ulcer disease. ncbi.nlm.nih.gov. https://www.ncbi.nlm.nih.gov/books/NBK534792/#:~:text=Peptic%20ulcer%20disease%20(PUD) %20is,the%20stomach%20and%20proximal%20duodenum. Mayo Clinic (2022 May 15) Gastritis mayoclinic org Retrieved November 6 2023 from

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