Week 3 Discussion Advance Practice

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South University College of Nursing and Public Health Graduate Online

Nursing Program

Aquifer Family Medicine

Family Medicine 19: 39- year-old man with epigastric pain

Author:Author: Joel Heidelbaugh, MD

INTRODUCTION HISTORY DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

MENUMENU

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Dr. Medel tells you about your next patient.Dr. Medel tells you about your next patient.

!

Today, you are working at a family medicine clinic with Dr. Medel. Together, you review her clinic schedule for the day and she suggests that you see Mr. Cesar Rodriguez, a 39-year-old uninsured man who recently moved to the U.S. from the Dominican Republic. This is Mr. Rodriguez's first visit to the clinic.

Molly, Dr. Medel's medical assistant, has already escorted Mr. Rodriguez to the examination room and has arranged for a Spanish-speaking interpreter to be present for the visit, since he speaks and comprehends very little English. Molly tells you that Mr. Rodriguez has been having "worsening abdominal pain over the past several months," and is "worried that something is wrong."

Dr. Medel says to you, "How would you begin to think about what might be going on with Mr. Rodriguez?"

You reply, "Abdominal pain can be caused by a wide variety of conditions. I'll need to get more information about his symptoms to form an appropriate differential diagnosis. At this point I'd have to consider several organ systems as potential etiologies of the pain."

"Very good," Dr. Medel responds. "Why don't you go ahead and talk with Mr.

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Rodriguez and come find me afterward. Lola, our Spanish-speaking interpreter can help."

Systems Approach to Abdominal Pain

Gastrointestinal

Appendicitis, cholecystitis/cholelithiasis, diverticulitis/diverticulosis, dyspepsia, gastroesophageal reflux disease, gastritis, acute or chronic hepatic failure with resultant complications (e.g., ascites), acute hepatitis (e.g., viral, autoimmune, alcoholic, drug-induced), inflammatory bowel disease, intestinal ischemia, intestinal obstruction, irritable bowel syndrome, pancreatitis, peptic ulcer, perforation/peritonitis (e.g., gastric, colonic, intestinal), gastric outlet obstruction, tumor (e.g., gastric, hepatic, pancreatic, intestinal, colonic).

Cardiac Myocardial infarction, angina pectoris, abdominal aortic aneurysm dissection or rupture.

Psychogenic Anxiety, panic disorder, somatiform disorder, post- traumatic stress disorder.

Pulmonary Pleurisy, pneumonia, pulmonary infarction, tumor.

Renal Nephrolithiasis, pyelonephritis, cystitis, tumor.

Musculoskeletal Abdominal wall muscle strain, hernia (e.g., ventral, inguinal, incarcerated), abscess (e.g., psoas, subphrenic), trauma (e.g., contusion, hematoma).

Metabolic Drug overdose, ketoacidosis, iron or lead poisoning, uremia.

Also consider:Also consider:

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medication, vitamin, and herbal supplement side effects foods issues (dietary intolerances, such as lactose, gluten, fructose, or

artificial sweeteners (e.g., sorbitol, xylitol, sucralose)

ELICITING THE HISTORY HISTORY

You and Lola greet Mr. Rodriguez.You and Lola greet Mr. Rodriguez.

!

How to Interview a Patient Via an Interpreter

Talk as you would normally, directly to the patient and not to the interpreter.

The translator should interpret in the first person, without editing it in any way.

Often, the interpreter will sit just behind the patient and in their ear, or off to the side where the interpreter won't obstruct your ability to face the patient, make direct eye contact, and feel like you're talking with the patient directly.

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Ideally, it should feel like the translator is just a conduit for the conversation between you and the patient.

As you walk down the hall, Lola, the Spanish-speaking interpreter, gives you some tips on how to interview a patient with an interpreter.

Then, you and Lola enter the room. You sit directly across from Mr. Rodriguez, with Lola sitting just off to your left and facing him. You sense that Mr. Rodriguez seems anxious about coming to the physician today. You introduce yourself and ask,

"What brings you in today?"

"Well, I've been having this abdominal pain, and it just seems like it won't go away. It started probably a year ago. It used to happen a few times a week, now it hurts every day. It usually burns right here." (He points to the epigastric area of his abdomen).

"Is there anything that makes the pain better or worse?"

"It's hard to say. Sometimes eating or drinking makes it better, or sometimes worse. Sometimes eating spicy foods makes it worse."

"What worries you the most about your symptoms?"

"I don't know," he says nervously. "I just want to make sure nothing is wrong."

Thinking about some of the common causes of abdominal pain, you conduct a focused review of systems:

General: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 travelled recently.

GI:GI: Denies any dysphagia, regurgitation, nausea, vomiting, anorexia, early

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satiety, hematemesis, hematochezia, melena, diarrhea or constipation. GU:GU: Denies dysuria, hematuria, or change in frequency. CVS/Respiratory:CVS/Respiratory: No chest pain or shortness of breath.

References

American Association of Medical Colleges. Guidelines for use of medical interpreter services. https://www.aamc.org/download/70338/data/interpreter-guidelines.pdf. Accessed April 21, 2017.

MEDICAL AND FAMILY HISTORY HISTORY You now direct your attention to Mr. Rodriguez's medical history.

"Do you have any chronic medical problems?"

"I don't really have medical problems, just the stomach pain."

"Have you ever been hospitalized or had any surgeries?"

"I've never been hospitalized. Never been operated on."

"Do you take any medicines or supplements?"

He tells you, "Just ibuprofen if I'm tired and sore after work, probably most days of the week. I drink some tea that's good for the stomach, 'Yerba Buena,' but it doesn't really help."

"Does anyone in your family have any medical conditions?"

"My father had high blood pressure, my mother had diabetes."

"Does anyone have pain similar to yours?"

"I don't know if anyone has these stomach problems like me."

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You ask Mr. Rodriguez a few more questions and discover that he works as a farm laborer. He has no known drug allergies. He smoked a few cigarettes daily, but quit six months ago. He drinks three to four beers per week. He denies other drug use.

You congratulate Mr. Rodriguez on quitting smoking and you thank him for answering all of your questions. You review in your mind what you've learned from Mr. Rodriguez so far, and find yourself still wondering about why he seems a little anxious. Before you go to get Dr. Medel, you inquire,

"It seems like this has really been bothering you. Is there anything else we haven't talked about that seems important?"

"Well, I guess I would have come sooner, but I don't have any health insurance and haven't had the money to come to the doctor. I want to feel better, but I hope it's not something serious."

ACCESS TO CARE TEACHING You reply, "Well, I'm glad you came in today, and I'll be sure and share your concern with Dr. Medel. Thanks for telling me."

You ask him to change into a gown, taking off all of his clothes except his underwear. You reassure him that you will return with Dr. Medel momentarily, and you and Lola leave the exam room while Mr. Rodriguez changes.

In the hallway, you comment to Lola that you are concerned about why Mr. Rodriguez waited to come see a doctor.

Question Which factors, in addition to finances, may have contributed to Mr. Rodriguez not seeking medical care in the recent months? Select all that apply.

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The best options are indicated below. Your selections are indicated by the shaded boxes.

A. He may be an undocumented immigrant.

B. Undocumented immigrants in the US are at a higher

risk of exploitation than legal residents.

C. Lack of concern about his overall health.

D. His impression that allopathic care is not considered

holistic.

E. He may view the U.S. healthcare system as unfriendly

and intimidating.

SUBMITSUBMIT

Answer Comment The correct answers are A, B, D, E.The correct answers are A, B, D, E.

Potential Cultural Barriers to Seeking Medical Attention

There may be a variety of reasons for an individual's reluctance to seek medical care, making it imperative that the physician explore and address these issues with each patient individually and not rely on assumptions about his or her reasons.

While all patients should be directly asked the reason for their reluctance to seek medical care, the patient’s occupation (farm worker) should raise a flag. Undocumented immigrants may fear that if they seek medical attention, the healthcare system may report them to the government, placing them at risk of deportation. This fear is not unfounded, and providers should be sensitive about disclosing patients' undocumented status.

Also, patients may view health from a holistic standpoint, where

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physical problems cannot be separated from non-physical problems; those with this viewpoint may be less likely to visit a physician's office or access preventive services, including vaccinations. This approach has been shown to improve health outcomes in some studies, and should not be dismissed.

Recent immigrants who are unfamiliar with the U.S. healthcare system can view it as confusing, intimidating, and unfriendly. (Even native residents of the U.S. may feel this way!) Latino patients may also be wary of receiving lower quality of a medical care and lower treatment standards because of discrimination and racism. Providers should actively check their biases to ensure they are providing an equal standard of care.

References

DeNavas-Walt C, Proctor B, Smith J. Income, Poverty, and Health Insurance Coverage in the United States: 2007. http://www.census.gov/prod/2008pubs/p60-235.pdf. Published August 2008. Accessed April 29, 2017.

Diaz VA. Hispanic male health disparities. In: Haines CA, Wender RC (eds.) Primary Care: Clinics in Office Practice. Philadelphia, PA: Saunders/Elsevier, 2006;33(1).

Hispanic population of the United States, US Census Bureau. http://www.census.gov/population/hispanic/. Accessed October 19, 2016.

MacNaughton NS. Health disparities and health-seeking behavior among Latino men: a review of the literature. Journal of Transcultural Nursing. 2008;19(1):83-91.

U.S. Census Bureau, 2010 Census Briefs: The Hispanic Population 2010. Issued May 2010. http://www.census.gov/prod/cen2010/briefs/c2010br-04.pdf

Wallace SP, Villa VM. Equitable health systems: cultural and structural issues for Hispanic elders. American Journal of Law and Medicine. 2003;29:247-267.

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SUMMARY STATEMENT CLINICAL REASONING

Dr. Medel asks you what you have learned about Mr. Rodriquez's historyDr. Medel asks you what you have learned about Mr. Rodriquez's history so far.so far.

!

You find Dr. Medel in the clinic precepting room, and she asks you, "Well, what have you learned so far?"

You summarize Mr. Rodriguez's story for Dr. Medel.

Question Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Guidelines for summary statements.

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A summary statement should:

1. Include accurate information and not include misleading information. 2. Facilitate understanding of the primary problem and appropriately narrow the differential diagnosis through the inclusion of pertinent key features. (The aim is to frame understanding of the primary problem rather than to report all information indiscriminately.) 3. Express key findings in qualified medical terminology (e.g., heart rate of 180 beats/minute is tachycardia); synthesize details into unifying medical concepts (e.g., retractions + hypoxia + wheezing = respiratory distress). 4. Use qualitative terms that are more abstract than patient's signs; these are often binary in nature (e.g., acute vs. chronic; constant vs. intermittent).

Ultimately, a good summary statement should provide an understanding of the patient presentation while being concise, complete, and accurate.

Your response is recorded in your student case report.

Letter Count: 0/1000

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SUBMITSUBMIT

Answer Comment Mr. Rodriguez is a previously well 39-year-old Latino immigrant who presents with chronic progressively worsening pain in his upper abdomen. He denies any vomiting, hematemesis, hematochezia, melena or association with meals. He recently quit smoking and consumes alcohol occasionally and takes NSAIDs and traditional herbal teas.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

Epidemiology and risk factors: 39-year-old previously well latino immigrant.

Key clinical findings about the present illness using qualifying adjectives and transformative language:

chronic progressively worsening no vomiting, hematemesis, hematochezia, melena, or association

with meals quit smoking occasional alcohol consumption uses NSAIDs uses traditional herbal teas.

DIFFERENTIAL DIAGNOSIS CLINICAL REASONING Dr. Medel praises your summary and then asks you to commit to a provisional differential diagnosis for Mr. Rodriguez's abdominal pain, based on your findings from his history.

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Question From the following, select the top three diagnoses on your differential.

A. Anxiety

B. Pneumonia

C. Gastroesophageal reflux disease (GERD)

D. Abdominal wall muscle strain

E. Acute Pancreatitis

F. Peptic ulcer disease (PUD)

G. Diverticulitis

H. Angina pectoris

I. Gastritis

SUBMITSUBMIT

Answer Comment The correct answers are C, F, I.The correct answers are C, F, I.

DiXerential for Chronic Progressively Worsening Upper Abdominal Pain

Most Likely / Most Important DiagnosesMost Likely / Most Important Diagnoses

May present with mild epigastric pain, and symptoms commonly worsen aftersymptoms commonly worsen after mealsmeals, although the pain is classicallyclassically

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GERDGERD

described as "burning"described as "burning" and may be located in the substernalsubsternal rather than epigastric area. Hematemesis in the setting of GERD-like symptoms is unusual and represents an alarm 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.

PepticPeptic ulcerulcer diseasedisease (PUD)(PUD)

Epigastric abdominal pain thatEpigastric abdominal pain that improves with mealsimproves with meals is the hallmark of PUD. However, in some cases, symptoms of PUD may worsen with meals. NSAIDNSAID 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 (e.g. NSAID-gastritits). Hematochezia only occurs in the setting of an upper GI bleed when massive (e.g. variceal rupture).

GastritisGastritis

Inflammation or irritation of the stomach lining often causing sharp epigastricsharp epigastric painpain. This pain may be variably worsenedworsened or improved with eating foodor improved with eating food. Inflammatory forms of gastritis may be caused by chronic infections such as H.H. pyloripylori or acute infections such as viruses.viruses. Non-inflammatory forms of 'gastritis' are more properly histologically termed

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gastropathy. These may be caused by chemical irritants to the stomach, including alcoholalcohol and NSAIDNSAIDs.

Less Likely DiagnosesLess Likely Diagnoses

Anxiety

A possible etiology for abdominal pain, but other diagnoses should be considered first. Can be associated with different types of body pain and patients who have anxiety disorders may self-medicate (i.e. with alcohol), which may warrant further careful exploration by the physician.

Pneumonia Unlikely in the absence of pulmonary symptoms.

Abdominal wall muscle strain

Can cause upper abdominal pain. This diagnosis is unlikely in the absence of a positional component to the pain.

Diverticulitis

Commonly presents with acute leftacute left lower quadrant abdominal pain,lower quadrant abdominal pain, change in bowel movements, andchange in bowel movements, and feverfever. Most common in patients over 50over 50 yearsyears of age.

Angina pectoris

Classically presents with substernalClassically presents with substernal chest painchest pain, but may present with epigastric abdominal pain andepigastric abdominal pain and nausea or vomitingnausea or vomiting. Interestingly, GERD is the most common cause of non-cardiac chest pain.

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Acute pancreatitis

Causes severe abdominal pain,severe abdominal pain, associated nausea and vomiting, illassociated nausea and vomiting, ill appearance on exam, and clinicalappearance on exam, and clinical signs of dehydration such assigns of dehydration such as tachycardia.tachycardia. Pain is typically located in the epigastricepigastric area with radiation to the backarea with radiation to the back and worsens with eatingworsens with eating. Symptoms often last for many hours without relief. Acute and chronic pancreatitis may be caused by alcohol usealcohol use. Remember that some patients may not be forthcoming about their actual alcohol use, especially if they perceive they are being judged or if they are in denial about problem use/abuse.

The absence of hematemesis, hematochezia, or melena is reassuring that significant GI bleeding is unlikely to be present, but does not help to distinguish between these three diagnoses, all of which can present without GI bleeding.

DYSPEPSIA DEFINED TEACHING

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You and Dr. Medel discuss dyspepsia.You and Dr. Medel discuss dyspepsia.

!

After careful consideration, you tell Dr. Medel that you are concerned that Mr. Rodriguez has either gastritis, gastroesophageal reflux disease (GERD), or peptic ulcer disease (PUD). You and Dr. Medel discuss the various causes of dyspepsia.

You tell Dr. Medel you are confused how to differentiate these etiologies of dyspepsia. Dr. Medel replies, "That is understandable, as this is like piecing together a puzzle. There is no one right answer for every patient. Instead, you have to consider the clinical picture as a whole. We'll need to consider each possible etiology for dyspepsia for Mr. Rodriguez."

Dyspepsia - DeYnition, Symptoms, Epidemiology & Etiology

DefinitionDefinition

Dyspepsia is literally "bad digestion."

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SymptomsSymptoms

Patients with this condition experience upper abdominal pain or discomfort that is episodic or persistent. It is often associated with belching, bloating, heartburn, nausea, or vomiting.

EpidemiologyEpidemiology

About a quarter of adults are affected by it, but many people self-diagnose and self-treat it. Even though most people don't seek medical care for it, dyspepsia accounts for approximately 5% of all visits to family physicians and is the most common symptom leading to GI referral in the US.

EtiologyEtiology

ConditionCondition % of Dyspepsia Cases% of Dyspepsia Cases

Functional or non-ulcer dyspepsia (specific etiology for dyspepsia can't be identified)

~ 50%

Peptic ulcer disease (PUD) 20%

GERD 20%

Gastritis / duodenitis 15%

Medication side effects Common

Pancreatitis Less common

Gastric, pancreatic, and esophageal cancer

Important though uncommon (< 2%)

Non-GI causes (such as angina and dissecting aortic aneurysm)

Rare, but should always be included in ddx

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Question Which of the following agents have been proven to cause or contribute to the development of peptic ulcer disease? Select all that apply.

A. Aspirin

B. Acetaminophen

C. Ibuprofen

D. Psychosocial stress

E. Moderate physiologic stress

F. Caffeine

G. Cigarette smoking

H. Helicobacter pylori

SUBMITSUBMIT

Answer Comment The correct answers are A, C, E, G, H.The correct answers are A, C, E, G, H.

Agents that Cause or Contribute to Peptic Ulcer Disease

Aspirin and other non-steroidal anti-inflammatory drugsAspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) are the predominant pharmacologic agents that(NSAIDs) are the predominant pharmacologic agents that contribute to the development of PUDcontribute to the development of PUD. Classically, the elderly are at the highest attributable risk of ulceration and perforation

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due to chronic NSAID use. Chronic NSAID use is a leading cause of morbidity in the elderly.

Moderate to severe physiologic stress may lead toModerate to severe physiologic stress may lead to stress ulcerationstress ulceration, predominantly in patients in the intensive care unit (ICU).

Colonization of the stomach byColonization of the stomach by H. pyloriH. pylori renders the underlying mucosa more vulnerable to peptic acid damage by disrupting the mucous layer, liberating enzymes and toxins, and adhering to the gastric epithelium. In addition, the body's immune response to H. pylori incites an inflammatory reaction that contributes to tissue injury and leads to chronic gastritis. In most individuals the chronic gastritis is asymptomatic and does not progress. In some cases, however, altered gastric secretion coupled with tissue injury leads to peptic ulcer disease. In other cases, gastritis progresses to mucosal atrophy, intestinal metaplasia, and eventually gastric carcinoma. Rarely, persistent immune stimulation of gastric lymphoid tissue can lead to gastric lymphoma.

There is no evidence to support a cause-and-effect association between cigarette smoking and PUD. However, cigarettecigarette smokingsmoking does decrease vascularity to gastric mucosal cells, resulting in decreased rates of mucosal healing after insult, and in combination with NSAID use or H. pylori infection, increases the risk of ulceration.

There is no evidence to support a cause-and-effect association between acetaminophen (B), psychosocial stress (D), or caffeine intake (F) and PUD.

References

Ford A., Moayyedi P. Current guidelines for dyspepsia management. digestive diseases: Clinical Reviews. Vol. 26, No. 3, 2008.

Fisher RS, Parkman HP. Management of nonulcer dyspepsia. N Engl J Med. 1998;339:1376-81.

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Heidelbaugh JJ, Inadomi JM. Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-intensive care unit hospitalized patients. Am J Gastroenterol. 2006;101(10):2200-5.

Spirt M, Stanley S. Update on Stress Ulcer Prophylaxis in Critically Ill Patients. Critical Care Nurse. Vol. 26 (1): February, 2006. http://ccn.aacnjournals.org/content/26/1/18.full. Accessed April 29, 2017.

Wight N, Hawkey C. Nonsteroidal anti-inflammatory drug-related peptic ulcer disease. In: Irvine E, Hunt R (eds). Evidence-based gastroenterology. Hamilton, Ontario: BC Decker; 2002:102-118.

CAUSES OF DYSPEPSIA TEACHING You tell Dr. Medel that you are still unsure how to differentiate between dyspepsia due to gastroesophageal reflux disease (GERD) and dyspepsia due to peptic ulcer disease (PUD).

Question Which of the following are TRUE regarding dyspepsia due to GERD or PUD? Select all that apply.

A. GERD can be distinguished from other gastrointestinal

disorders with reasonable accuracy on the basis of …