Nursing

Discussion #1

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 who recently moved to the United States from the Dominican Republic. He presents with a history with abdominal pain that has become increasing worse over the last several months, but began about a year ago. When the pain first started it occurred a few times a week and now he it occurs daily. He states that it is a burning pain and points to his epigastric region. He recently quit smoking and drinks 3-4 alcoholic drinks per week. He also reports using NSAID’s on most days of the week to deal with aches and pains from his work. Mr. Rodriguez denies surgical history, relevant family history (father has HTN and mother has Diabetes) or significant person medical history other than the abdominal pain (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? 

 

Mr. Rodriguez’s physical exam appears to be normal except for the minimal tenderness to the epigastric region upon deep palpation.  His physical exam is below:

 

“Vital Signs:

Temperature: 98.5 Fahrenheit

Heart Rate: 78 beat/minute

Respiratory Rate: 15 breaths/minute

Blood Pressure: 123/72 mmHg

Body Mass Index: 24.8

 

General: Middle aged man that appears well but anxious.

Neck: Supple, no mass, lymphadenopathy or thyromegaly

Cardiovascular: Regular HR and rhythm, S1, S2, no murmurs, rubs or gallops.

Respiratory: Bilaterally clear lungs to auscultation without wheezes, rales or rhonchi.

Abdominal: Flat appearance without scars. Normoactive bowel sounds heard in four quadrants. Soft, non-distended, with minimal epigastric tenderness on deep palpation without rebound tenderness or guarding, no hepatosplenomegaly, and no hernia or masses.

Skin: Tanned, no jaundice, several tattoos on his upper extremities, no suspicious lesions

Extremities: Warm and well-perfused, no cyanosis, clubbing or edema (Heidelbaugh, n.d.).”

 

In this case study the suspected diagnosis is GERD, because of this diagnosis Mr. Rodriguez is placed on an empiric medication trial with proton pump inhibitor (PPI) for one month. He was also instructed to cut back on alcohol, caffeine, spicy foods, and ibuprofen and to substitute for acetaminophen instead when needed. At Mr. Rodriguez’s four week (one month) follow up he stated that “the medicine did not work even though he took it correctly” and that he still has a burning pain in his epigastric area. Since his treatment was not effective at that time other options for diagnoses were discussed. A H.pylori IgG serology test, CBC, digital rectal exam with guaiac-based fecal occult blood test are all done at that time.

 

“Vital Signs:

Heart Rate: 80 beats/minute

Blood Pressure: 126/75 mmHg

 

Abdominal Exam: He has minimal epigastric tenderness without rebound or guarding, which is unchanged compared to his previous exam four weeks ago.

Rectal Exam: Reveals a negative FOBT test, without any evidence of gross blood or anatomic abnormality.

H. pylori IgG Serology: Positive

CBC: Unremarkable for anemia (Heidelbaugh, n.d.).”

 

I would not have done any additional testing, however since Mr. Rodriguez recently moved to the United States and is from a country that H. pylori is prevalent I would have considered doing the h.pylori faecal antigen test at the first visit. “Although guidelines for the management of dyspepsia advocate a ‘test and treat’ policy for Helicobacter pylori (Elwyn et al., 2007) the faecal antigen tests proves to be most cost effective and gives less false positives’ than the other two tests (breath test and serology). I understand that Mr. Rodriguez is worried about money since he does not have health insurance but I would have at least discussed this test with the supervising doctor because of his social history.

 

 

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?

 

GERD- Mr. Rodriguez presents with epigastric pain that is sometimes worse after meals, especially spicy food that he described as a “burning” sensation. Mr. Rodriguez has no signs of hematemesis, hematochezia or melena which is consistent with GERD (Heidelbaugh, n.d.).

 

Peptic Ulcer Disease (PUD) – Mr. Rodriguez presents with epigastric pain that sometimes improves after he eats but is sometimes worse after he eats. He also takes NSAID’s on a daily basis for aches and pains from work (Heidelbaugh, n.d.).

 

Gastritis- Mr. Rodriguez presents with epigastric pain that is sometimes better and sometimes worse after eating food. He also has a history of daily NSAID use and admits to alcohol use which can sometimes irritate the stomach lining. He also recently moved from a country that has a higher prevalence for H. pylori that can cause inflammation and pain from irritation (Heidelbaugh, n.d.).

 

The final diagnosis is Gastritis that was caused by a chronic H. pylori infection. This was discovered after a positive serology test and the PPI treatment was not effective after several weeks.

 

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?

 

Once Mr. Rodriguez was diagnosed with H. pylori he should be started on a triple therapy to treat the infection. The triple therapy treatment is a fourteen day regimen of a standard PPI dose twice a day, Amoxicillin 1 g twice a day, Clarithromycin 500 mg twice a day (Heidelbaugh, n.d.).

 

After Mr. Rodriguez completed his triple therapy he returned to the office for a follow up visit. He complained that his symptoms had returned. At that time Mr. Rodriguez was diagnosed with persistent H. pylori, which means that he needed to be treated with salvage therapy. Salvage therapy consists of bismuth quadruple therapy or levofloxacin- based triple therapy. Mr. Rodriguez was treated with a standard PPI dose twice daily, Metronidazole 250 mg four times daily, Tetracycline 500 mg four times daily, and Bismuth subsalicylate 525 mg four times daily. Two weeks after completing the salvage therapy for H. pylori he was completely symptom free (Heidelbaugh, n.d.).

 

When working with Mr. Rodriguez it is important to remember that English is not his first language and an interpreter must always be used that way he is able to fully understand all of the information given to him. It would be beneficial to use verbal, written handouts (in his primary language) and a teach-back method when working with him. Mr. Rodriguez should be educated on limiting or stopping his use of alcohol and eliminating NSAIDs from his routine. He should know that using alcohol or NSAIDs could increase his chances of creating an ulcer, bleeding or other GI issues. If he is having aches and pains from work and absolutely needs something he should instead use acetaminophen. He should be educated on the warning signs of GI issues that require emergency medical treatment, these symptoms include black, sticky, tarry stools or emesis that is bloody or looks like coffee grounds (Heidelbaugh, n.d.). Mr. Rodriguez should be educated on all his medications, when to take them, how to take them and what side effects could occur. Mr. Rodriguez should also be made aware that herbal remedies (such as the tea he drinks) are not regulated by the US Food and Drug Administration and may not be safe, could have adverse effects or interact with his medications. He should be set up with a case manager that way they are able to help him get health insurance this way he will be more likely to get treatment if the issue reoccurs and to maintain a healthy lifestyle with regular check-ups. If Mr. Rodriguez’s symptoms reoccur after the Salvage Treatment he should be referred to a GI specialist at that time.

Discussion #2

Patient is Mr. Cesar Rodriguez, a 39-year-old, first visit to the clinic. He is uninsured and recently moved to the U.S. from the Dominican Republic. A Spanish-speaking interpreter needs to be present for the visit, since he speaks and comprehends very little English.

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.

CC: “worsening abdominal pain over the past several months,” and is “worried that something is wrong.”

HPI: Using the acronym OLDCARTS (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity).

Mr. Rodriguez is a previously well 39-year-old Latino immigrant who presents with chronic, progressively worsening pain in his upper abdomen. He complained of having this abdominal pain, that seems like it won’t go away. It started probably a year ago. It used to happen a few times a week, and now it hurts every day. It usually burns right at the epigastric area of his abdomen. Eating or drinking makes the pain better sometimes, or sometimes worse. However, eating spicy foods makes it worse sometimes.

ROS: General: 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 traveled recently. GI: Denies any dysphagia, regurgitation, nausea, vomiting, anorexia, early satiety, hematemesis, hematochezia, melena, diarrhea, or constipation. GU: Denies dysuria, hematuria, or change in frequency. CVS/Respiratory: No chest pain or shortness of breath.

PMH: No past medical problems, just that stomach pain. No surgical history.

Medication/herbal remedies: NSAIDs and traditional herbal teas. He takes Ibuprofen for tiredness and soreness after work, probably most days of the week. Drinks tea ‘Yerba Buena,’ for the stomach, but it does not help.

Significant family Hx: Father had high blood pressure, and the mother had diabetes. No knowledge of any family history of stomach problems.

Social Hx: He works as a farm laborer. Smoker, he smoked a few cigarettes daily but quit six months ago. He drinks three to four beers per week. He denies any other drug use.

Allergies: He has no known drug allergies.

Psychological assessment: Anxious because he would have come sooner, but don’t have any health insurance and haven’t had the money to go to the doctor. He wants to feel better but hopes it’s not something serious.

Apart from his financial status, other factors that may have contributed to Mr. Rodriguez not seeking medical care early (in recent months) includes; he may be an undocumented immigrant. Undocumented immigrants in the U.S. are at a higher risk of exploitation than legal residents. Findings from a study by Becerra, Wagaman, Androff, Messing and Castillo in 2017, revealed that immigrants often struggle to adapt to a new culture, which combined with experiences of discrimination, lead to increased stress among immigrant populations. According to the authors, immigrants in the U.S. are classified as legal residents if they were granted lawful permanent residence; granted asylee status; admitted as refugees; or admitted as nonimmigrants for a temporary stay in the U.S. Immigrants are classified as unauthorized or undocumented if they do not have permanent legal residence status because they entered the U.S. without inspection or overstayed their visas (Becerra et al., 2017).

Mr. Rodriguez may have the impression that allopathic care is not considered holistic. Patients who view health from a holistic standpoint, where physical problems cannot be separated from non-physical issues; those with this viewpoint may be less likely to visit a physician’s office or access preventive services, including vaccinations. He used tea – ‘Yerba Buena’ for relief of his symptoms when he needed medical care. According to Master Herbalist, Paul Haider, ‘Yerba Buena’ is from the mint family that grows worldwide. It is believed to be great for relaxing the mind/body and spirit, and useful for relaxing the GI tract, aids in digestion, and relieves stomach aches and gas (Haider, 2011). Other uses include – for pain reliever (analgesic) effects, relief of arthritis pain, headaches, toothaches, and the mint flavor makes it a great mouthwash (Haider, 2011). It contains polyphenols such as caffeine, caffeic acid, catechin, and quercetin, which are high antioxidants that improve the cardiovascular and immune system health (Haider, 2011).

Another factor may have been that he viewed the U.S. healthcare system as unfriendly and intimidating. Roche, Vaquera, White, and Rivera (2018) study gives an empirical account of how recent immigration policy changes and news have impacted the lives of Latino families raising adolescent children. Recorded harmful impacts manifested across a range of parent concerns and behaviors and are strong correlates of psychological distress (Roche et al., 2018).

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? 

Vital signs: Temperature: 98.5 Fahrenheit; Heart rate: 78 beats/minute, regular; Respiratory rate: 16 breaths/minute; Blood pressure: 123/72 mmHg; Body Mass Index: 24.8 kg/m2

General: Well-appearing, middle-aged man.

Head, eyes, ears, nose and throat (HEENT): Sclera anicteric, no conjunctival pallor, oropharynx without lesion or significant dental abnormality.

Neck: Supple, no mass, lymphadenopathy or thyromegaly.

Cardiovascular: Regular heart rate and rhythm, S1, S2, no murmurs, rubs, or gallops.

Respiratory: Bilaterally clear lungs to auscultation without wheezes, rales or rhonchi.

Abdominal: Flat appearance without scars. Normoactive bowel sounds heard in four quadrants. Soft, non-distended, with minimal epigastric tenderness on deep palpation without rebound tenderness or guarding, no hepatosplenomegaly, and no herniae or masses.

Skin: Tanned; no jaundice, several tattoos on his upper extremities, no suspicious lesions.

Extremities: Warm and well-perfused, no cyanosis, clubbing or edema.

Diagnostic tools

From the objective findings, there are no alarming symptoms and signs of complications that would prompt immediate gastroenterology referral. An empiric treatment strategy is the most widely accepted initial therapeutic intervention for GERD, gastritis, and PUD patients without red flag symptoms. One of Mr. Rodriguez diagnosing factor is dyspepsia, a chronic or recurrent abdominal pain or discomfort centered in the upper abdomen According to Moayyedi, Lacy, Andrews, Enns, Howden, and Vakil (2017), it is a common clinical feature of PUD. Another is the “pointing sign,” patient can show the site of pain with one finger.

The first steps in diagnostic testing and therapeutic planning for Mr. Rodriguez are the use of an empiric treatment strategy that begins with a self-directed trial of over-the-counter anti-secretory therapy, either a histamine-2 receptor antagonist or a proton-pump inhibitor (PPI). According to a World Gastroenterology Organization (WGO) global guidelines, a formal course of PPI therapy, of adequate duration (usually 8 weeks) is required to assess the treatment response in GERD patients (Hunt, Armstrong, Katelaris, Afihene, Bane, Bhatia & Ford, 2017). Endoscopy (EGD) is usually performed for new-onset upper GI symptoms, almost irrespective of age, in regions where it is available and affordable and where both the frequency of ulcer disease and the concern about malignancy are high, as in most of Asia (Hunt et al., 2017).

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?

Three differential diagnosis for Mr. Rodriguez

· Gastroesophageal reflux disease (GERD)

· Peptic ulcer disease (PUD)

· Gastritis

Gastroesophageal reflux disease (GERD): May present with mild epigastric pain, classically described as “burning” usually located in the substernal rather than epigastric area. However, the symptoms commonly worsen after meals. Hematemesis in the setting of GERD-like symptoms is unusual and represents an alarming symptom indicative of an upper GI bleed or tumor and warrants prompt GI referral for evaluation and upper endoscopy. Hematochezia and melena are not typically associated with GERD.

Peptic ulcer disease (PUD: The hallmark of PUD is epigastric abdominal pain that improves with meals. NSAID use is associated with the development of PUD. Hematemesis, if present, suggests more complicated disease including bleeding ulcer and warrants urgent GI referral and endoscopy. Melena commonly occurs in the setting of an upper GI bleed secondary to PUD or hemorrhagic gastritis (example NSAID-gastritis). Hematochezia only occurs in the situation of an upper GI bleed when massive (such as variceal rupture).

Gastritis: Inflammation or irritation of the stomach lining, often causing sharp epigastric pain. This pain may be variably worsened or improved with eating food. Inflammatory forms of gastritis may be caused by chronic infections such as H. pylori or acute infections such as viruses. Non-inflammatory forms of ‘gastritis’ are more appropriately histologically termed gastropathy. Chemical irritants may cause these to the stomach, including alcohol and NSAIDs

My first impression is that Mr. Rodriguez is suffering from gastritis. However, with his report of chronic upper abdominal pain related to eating a meal (dyspepsia) and the use of ibuprofen, I leaned towards PUD. Non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen are the predominant pharmacologic agents that contribute to the development of PUD.

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 goal of therapy for PUD is to treat complications (like active bleeding), eliminate the underlying cause whenever possible, relieve symptoms, and heal ulcers. Mr. Rodriguez will be placed on Omeprazole, which may help alleviate his pain and heal a possible ulcer. Omeprazole is a proton pump inhibitor that decreases the amount of acid produced in the stomach. He will take 20 mg every day for four weeks, on an empty stomach, 30 minutes before the first meal of the day. Mr. Rodriguez is instructed to cut back on alcohol, caffeine, spicy foods, and substitute ibuprofen with acetaminophen. Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, should be ceased before treatment.  Mr. Rodriguez would be instructed on Omeprazole uses, the possible side effects, and what to watch out for while taking this medication. Patient would be advised to seek medical attention if he develops blood in stools, black tarry stools, vomiting, or abdominal pain.

Mr. Rodriguez may be needing help with paying for his office visit and for medication, so he would be recommended to a patient assistance program. The next follow-up visit scheduled in one week.

Discussion #3

Mr. Rodriguez is a 39-year old Latino male who presents today in clinic with epigastric pain. Patient states the pain started approximately 1 year ago; however, the pain has progressively gotten worst in his upper abdomen area. Mr. Rodriguez describes the pain as burning. The patient has noted that the pain is worse when eating spicy foods. To relieve the pain, the patient states he takes Ibuprofen and drink Yerba Buena tea; however, it does not relieve the pain. The patient denies fevers, chills, weight loss, or night sweats. Besides from his recent move to the United States (US) from the Dominican Republic (DR), he has not had any recent travels. Denies nausea, anorexia, hematemesis, melena, dysphagia, regurgitation, early satiety, constipation or diarrhea. Denies hematuria, dysuria or change in frequency. Denies any allergies to food or medications. Patient admits to drinking 4 beers throughout the week and smoking, which he stopped 6 months ago. Mother had a history of diabetes and father had hypertension.

PHYSICAL EXAMINATION

Vital signs:

· Temperature: 98.5 Fahrenheit

· Heart rate: 78 beats/minute, regular

· Respiratory rate: 16 breaths/minute

· Blood pressure: 123/72 mmHg

· Body Mass Index: 24.8 kg/m2

General: Well-appearing, middle-aged man.

Head, eyes, ears, nose and throat (HEENT): Sclera anicteric, no conjunctival pallor, oropharynx without lesion or significant dental abnormality.

Neck: Supple, no mass, lymphadenopathy or thyromegaly.

Cardiovascular: Regular heart rate and rhythm, S1, S2, no murmurs, rubs, or gallops.

Respiratory: Bilaterally clear lungs to auscultation without wheezes, rales or rhonchi.

Abdominal: Flat appearance without scars. Normoactive bowel sounds heard in four quadrants. Soft, non-distended, with minimal epigastric tenderness on deep palpation without rebound tenderness or guarding, no hepatosplenomegaly, and no hernia or masses.

Skin: Tanned; no jaundice, several tattoos on his upper extremities, no suspicious lesions.

Extremities: Warm and well-perfused, no cyanosis, clubbing or edema.

Diagnostic Test Results:

· Helicobacter Pylori IgG Antibody by EIA – Qualitative: Positive (H. pyloriIgG antibody       detected)

· Digital rectal examination – Negative FOBT

The diagnostic tests performed on Mr. Rodriguez were appropriate and specific for his presenting symptoms. Another test I would have wanted completed that wasn’t completed in the case study is to obtain in a complete blood count (CBC). Results will determine if the patient’s hemoglobin is low. A low hemoglobin can indicate possible gastrointestinal bleeding or anemia (Fischbach & Dunning, 2015).

DIFFERENTIAL DIAGNOSIS

1. Gastroesophageal Reflux Disease (GERD). The reason I chose GERD as a possible diagnosis is because of how he explained his symptoms alone. As stated previously, Mr. Rodriguez described the pain as a burning sensation and usually occurs after spicy meals.  According to Heidelbaugh (n.d.), patients that have gerd symptoms often worsen after meals are consumed and describes the pain as burning.

2. Peptic Ulcer Disease (PUD): PUD was a part of my differential diagnosis due to the patient’s symptoms (epigastric pain) and his way of self-medicating to relieve the pain (taking ibuprofen). According to Heidelbaugh(n.d.), the use of NSAIDs is associated with the development of PUD.

3. Gastritis: Gastritis was also a part of the differential diagnosis due to the patient’s symptoms (pain worsening after meals) and the different chemical irritants he admits to consuming (alcohol and NSAIDs). According to Heidelbaugh (n.d.), alcohol and NSADs are considered chemical irritants and the use of them can irritate the stomach lining causing sharp epigastric pain.

FINAL DIAGNOSIS

H. Pylori

Although GERD or PUD was considered to be the cause of Mr. Rodriguez’s epigastric pain; H. Pylori ultimately ended up being the cause. When Mr. Rodriguez was empirically treated with a 4-week supply of omeprazole, which is a PPI and educated on the importance of dietary and lifestyle modifications, the symptoms remained. Because initial treatment management did not work, further workup was needed. Based on the H. Pylori IgG serology that was ordered, the results came back positive which indicates a positive diagnosis for H. Pylori.

PLAN OF CARE

First line treatment for H. pylori consist of prescribing 3 medications for a total of 10-14 days. The medications are omeprazole (20mg twice daily), amoxicillin (1 gram twice daily) and clarithromycin (500mg twice a day) (Heidelbaugh, n.d.).  Patient education should also be given to the patient. Education should be should be provided on possible side effects of the medications; such as: alterations in taste, diarrhea, nausea and abdominal pain (Heidelbaugh, n.d.).  Also will provide the possibility of an allergic reaction with taking any medications; such as swelling and generalized rash and to call the clinic if he experiences these symptoms. The patient would be education to immediately call 911 and to go to the emergency room if his throat starts to swell and he is experiencing voice changes. I will also stress the importance of medication adherence and to complete the course of antibiotics to prevent antibiotic resistance. The patient would be encouraged to follow back up in four weeks.

Discussion #4

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 Hispanic male who recently moved to the USA from the Dominican Republic. He is complaining of a chronic abdominal pain that started a year ago intermittently and now it seems to be constant. and seems getting worse. Mr. Rodriguez described the pain as a burning pain to the epigastric area of his abdomen which is worse whit spicy foods. He admits that he takes Ibuprofen on a daily basis when feeling tired and sore after work and drinks some herbal tea – Yerba Buena- for his stomach that does not help. Yerba Buena has long been used to provide relief for abdominal pain, indigestion, loss of appetite, passage of gas, diarrhea and stomach ache. It is known to relax the digestive tract muscles Herbal Medicine, 2011).  He also drinks three to four beers a week and quit smoking 6 months ago. Mr. Rodriguez denies any other symptoms such as nausea, vomiting, dysphagia, diarrhea, regurgitation or constipation. While questioning Mr. Rodriguez about his family history, he states that his dad had hypertension and his mother was diabetic. He admits that he did not consult earlier because he has no health insurance and have not had the money to come to the doctor (Heidelbaugh, n.d.). Barriers to health care for undocumented immigrants go beyond policy and range from financial limitations, to discrimination and fear of deportation. Hacker et al. (2015) consider fear of deportation, communication ability, financial resources, shame and knowledge about the health care system as individual barriers to care among immigrants. They identified that undocumented immigrants avoid health care and wait until health issues are critical to seek services because of their concerns of being reported to authorities, their inability to speak the language of the dominant culture and the cultural discomfort with the way in which the dominant culture communicated. The authors add that these immigrants are unable to communicate their health concerns to care providers or were misunderstood by those providers.

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 middle age man well appearing. His physical exam is unremarkable and vital signs within normal limits. His lungs are clear, and the exam of the abdomen reveals normal bowel sounds, no palpable masses, no distension but a minimal epigastric tenderness. His heart rate is regular, no murmurs, rubs or gallops identified. Mr. Rodriguez skin does not show jaundice or any suspicious lesions.

In addition to the digital rectal examination, the H. Pylori IgG serology, and the CBC, since there is no improvement in the symptoms, I will order an endoscopy to look for ulcers and if ulcers identified, samples will be sent to the lab for biopsy. may be removed for examination in a lab. According to mayo Clinic (2019), a biopsy can also identify whether H. pylori is in the stomach lining, the primary identified cause of gastric cancer (National Cancer Institute, 2013).

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?

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