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?
The three diagnostic differentials will be Gastroesophageal reflux disease (GERD), Peptic Ulcer Disease (PUD) and Gastritis. Mr. Rodriguez describes his pain as a burning at the epigastric area. GERD can be considered since one of the most common symptoms of GERD is heartburn which is a retrosternal area pain (Buttaro, T., Trybulski, J., Polgar-Bailey, P., Sandberg-Cook, J., 2014; p.669). Gastritis can be considered as a differential diagnostic as well since the inflammation of the stomach causes sharp epigastric pain that may be worsened or improved with eating food (Heidelbaugh, n.d.). Finally, peptic ulcer disease can be also considered because of the daily use of NSAID by the patient.
The final diagnosis is Peptic Ulcer Disease (PUD). According to Buttaro et al., (2017), the two-common cause of PUD in the United states are Helicobacter infection- helicobacter pylori- and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) (p.728). Mr. Rodriguez reported using Ibuprofen on a daily basis when tired and feeling sore after work.
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?
If NSAIDs such as ibuprofen use is documented, the medication should be discontinued. Mr. Rodriguez should be placed on omeprazole- a Proton Pump inhibitor (PPI) that could help with the pain. If no improvement, treatment for H. Pylori should be initiate with one of the 4 options for treatment of H. pylori infection (Buttaro et al. 2017, p. 729, table 144-1).
Patient should be educated on dentification and modification of risk factors, such as cigarette smoking, alcohol, stress, spicy food and use of NSAIDs. Patient will also be educated on signs and symptom of complications specifically hemorrhage, perforation, GI bleeding and anemia. Compliance with medication will be encouraged and reviewed with Mr. Rodriguez. He needs to know that a follow-up endoscopy should be performed after treatment to show that everything healed (Mayo clinic, 2019), even if his symptoms improve and will be encouraged to keep his appointment with his provider 4 weeks after H. Pylori treatment.