Reply to my peers

Peer 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.

Chief Complaint: worsening abdominal pain over the past several months" and is "worried that something is wrong."

HPI: Started probably a year ago. It used to happen a few times a week, now it hurts every day. It usually burns right here

Family: Father had high blood pressure and mother had diabetes

Past Medical History: None

Social: Takes ibuprofen if tired and sore after work, probably most days of the week. Drinks some tea that's good for the stomach—Yerba Buena—but it doesn't really help.". Drinks 3-4 beers weekly, use to smoke regularly but has quit approximately 6 months ago. Also recently came from Dominican Republic and does not have health insurance; thus explaining why he has not come sooner for his issue

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?

· Temperature is 36.9 C (98.5 F)

· Pulse is 78 beats/minute, regular

· Respiratory rate is 16 breaths/minute

· Blood pressure is 123/72 mmHg

· Body mass index is 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 to auscultation and percussion without wheezes, rales or rhonchi.

Abdominal: Symmetric appearance without scars or ecchymosis. Normoactive bowel sounds heard in four quadrants. Soft, nondistended, 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.

 

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 different diagnosis that I initially chose included gastritis, peptic ulcer disease and GERD. I chose these three because they all deal with the abdominal area and considering he takes ibuprofen regularly; there are different elements and components within the medication that can cause issues with the stomach.

· GERD is the diagnosis that I made upon completion of his physical exam. While his physical exam did not show any specific physical indications of GERD; his overall symptoms and current life habits prove to be the primary indication of this specific ailment.

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 first component to assisting Mr. Rodriquez is his diet; ensuring he understands the importance of cutting back on caffeine, alcohol, and the amount of ibuprofen that he is consuming.

· Kulinna (2019) discusses the element of swallowing MRI which provides a inside look into the esophagous and overall abdominal system. It allows for a more extensive outlook of the abdominal area. This type of testing is also said to “better understand GERD” (Kulinna, 2019, p237).

· It is imperative that Mr. Rodriquez also be referred to a gastroenterologist as well to better review and observe his symptoms.

 

Reference

Kulinna-Cosentini, C., Arnoldner, M. A., Kristo, I., Jomrich, G., Schima, W., Riegler, M., Schoppmann, S. F., & Cosentini, E. P. (2019). Swallowing MRI for GERD—diagnosis and treatment monitoring. European Surgery: ACA Acta Chirurgica Austriaca, 51(5), 231–238. https://doi-org.su.idm.oclc.org/10.1007/s10353-019-0601-1