Introduction
Mr. Rodriguez, a 39-year-old male, recently migrated from the Dominican Republic to the US. The patient’s medical history reveals that he has been experiencing chronic abdominal pain that has progressively worsened over time. Given these symptoms, further diagnostic testing may be necessary to determine the underlying cause of the pain. This essay will discuss his history pertinent to his gastrointestinal problem, the physical exam and diagnostic tools used, the differential diagnoses, and the care plan.
Patient History: Relevant Factors for Mr. Rodriguez’s Gastrointestinal Problem
Mr. Rodriguez’s main complaint is: “I’ve been having this abdominal pain, and it just seems like it won’t go away.” Mr. Rodriguez’s history of present illness (HPI) involves epigastric discomfort that began around a year ago. He described the discomfort as burning and daily. He claims that eating causes the pain to intensify at times and improve at others. He admits to using NSAIDs every week and consuming 3-4 drinks of alcohol each week.
The patient denies experiencing symptoms such as nausea, hematemesis, hematochezia, or melena. Mr. Rodriguez has no substantial medical history, chronic medical conditions, or surgical history. His father had high blood pressure, and his mother had diabetes. His social history indicates that he quit smoking six months ago and drinks 3-4 beers weekly.
Physical Examination and Diagnostic Tools for Mr. Rodriguez
Mr. Rodriguez appeared to be in good health upon physical examination. The vital signs are typical, and the physical exam is uneventful. The initial diagnostic technique for GERD included short-term therapy with a proton pump inhibitor (PPI) to assess if symptoms were eased, but Mr. Rodriguez’s ailments were not alleviated. Mr. Rodriguez underwent a fecal occult blood test, H. pylori serology test, CBC with differential, upper GI endoscopy, upper GI series, and chest x-ray. He proved positive for H. pylori, confirming a peptic ulcer caused by H. pylori. To check for H. pylori eradication, additional diagnostic methods such as an H. pylori antigen test or urea breath test should be employed.
Differential Diagnoses for Mr. Rodriguez: Rationale and Final Diagnosis
Mr. Rodriguez’s differential diagnoses include gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), and non-ulcer dyspepsia. Heartburn, an unpleasant burning feeling, and acid regurgitation are symptoms of GERD, which are increased by fatty meals, coffee, and a supine position (Jung et al., 2021). PUD is a pathologic, chronic condition characterized by stomach and intestinal mucosal ulcers (Sverdén et al., 2019).
Mr. Rodriguez’s symptoms are consistent with the clinical presentation of epigastric discomfort and dyspepsia. Non-ulcer dyspepsia is defined as chronic dyspeptic symptoms such as epigastric or upper abdominal pain or discomfort that is episodic or continuous (Ford et al., 2020). The final diagnosis for Mr. Rodriguez was peptic ulcer disease due to H. pylori.
Plan of Care for Mr. Rodriguez: Drug Therapy, Treatments, and Patient Education
Mr. Rodriguez’s treatment strategy will include education on the illness process and the initiation of treatment. For several weeks, the first line of medical care is Clarithromycin triple therapy, which consists of a PPI, clarithromycin, and amoxicillin or metronidazole (Ford et al., 2020). Education would cover how to take the prescriptions, warning signals, potential side effects, allergic responses, and when to contact the doctor’s office.
Mr. Rodriguez will be seen in four weeks to have his condition re-evaluated. Mr. Rodriguez’s symptoms will be monitored to see whether they have improved. If symptoms do not improve, further testing, such as an H. pylori antigen test or urea breathing test, will be performed to ensure H. pylori elimination. If medication does not alleviate symptoms, a referral to a gastroenterologist is needed.
Conclusion
In conclusion, Mr. Rodriguez presents with chronic, progressively worsening abdominal pain. Upon examination, he tested positive for H. pylori, a bacterium known to cause peptic ulcers. The care plan for Mr. Rodriguez includes education on the disease process, which will help him better understand his condition and how to manage it. Starting treatment with triple clarithromycin therapy is also part of the plan. This treatment involves taking three medications to kill the H. pylori bacteria and reduce the inflammation in the stomach lining. Finally, Mr. Rodriguez will have a follow-up appointment in four weeks to re-evaluate his condition and ensure he responds well to treatment.
References
Ford, A. C., Mahadeva, S., Carbone, M. F., Lacy, B. E., & Talley, N. J. (2020). Functional dyspepsia. The Lancet, 396(10263), 1689–1702. Web.
Jung, H. K., Tae, C. H., Song, K. S., Kang, S. G., Park, J., Gong, E. J., Shin, J. H., Lim, H., Lee, S. Y., Jung, D. H., Choi, Y. Y., Seo, S. I., Kim, J. B., Lee, J. P., Kim, B. J., Kang, S. C., Park, C. B., Choi, S. C., Kwon, J. G.,… Lee, K. Y. (2021). 2020 Seoul consensus on the diagnosis and management of gastroesophageal reflux disease. Journal of Neurogastroenterology and Motility, 27(4), 453–481. Web.
Sverdén, E., Agréus, L., Dunn, J. M., & Lagergren, J. (2019). Peptic ulcer disease. BMJ, l5495. Web.