Case Analysis Tool Worksheet Student’s Name: CASE ID: Family Medicine 19 I. Epidemiology/Patient Profile Mr. Cesar Rodriguez is a 39-year-old uninsured male who recently moved to the U.S. and presented with worsening abdominal pain over the past several months. II. Prioritized Cues from Hx and PE. (Do not include lab, X-ray, or other diagnostic test results here) Tier 1: The cues (may be negative or positive) that contribute most to the diagnosis of the active problem Tier 2: These are cues of intermediate importance (list only positive cues) Tier 3: Of least importance (list only positive cues) • Tier 1 Tier 2 Tier 3 Chronic progressive worsening epigastric pain for about a year My father had high blood pressure; my mother had diabetes No chronic medical condition Eating or drinking sometimes makes it better He has no health insurance Never been hospitalized or had any surgery Eating spicy foods sometimes makes it worse No weight loss, fevers, chills, or night sweats Immigrant from Dominican Republic Denies hematemesis, hematochezia, or melena stools Denies, nausea, vomiting, anorexia, early satiety, diarrhea, or constipation. Denies dysphagia, regurgitation Previous smoker (quit 6 months ago) Drinks alcohol occasionally Takes Ibuprofen (NSAIDs) for pain most days This study source was downloaded by 100000804629821 from CourseHero.com on 11-23-2021 20:12:14 GMT -06:00 https://www.coursehero.com/file/75500729/AQ4-Family-Medicine-19pdf/ This study resource was shared via CourseHero.com Takes traditional herbal teas Epigastric tenderness on deep palpation without rebound tenderness or guarding, III. Problem Statement Mr. Rodriguez is a 39 y/o Latino immigrant who has been previously well and presents today 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. He also takes NSAIDs and traditional herbal teas. IV. Differential Diagnosis Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s). List your most likely diagnosis first, followed by two other reasonable possibilities. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and the physical examination that support each diagnosis. Leading dx: Peptic Ulcer Disease History Finding(s) Physical Exam Finding(s) Chronic progressive worsening epigastric pain for about a year Epigastric tenderness on deep palpation without rebound tenderness or guarding Eating or drinking sometimes makes it better Eating spicy foods sometimes makes it worse Takes Ibuprofen (NSAIDs) for pain most days Denies hematemesis, hematochezia, or melena stools Denies dysphagia, regurgitation Drinks alcohol occasionally This study source was downloaded by 100000804629821 from CourseHero.com on 11-23-2021 20:12:14 GMT -06:00 https://www.coursehero.com/file/75500729/AQ4-Family-Medicine-19pdf/ This study resource was shared via CourseHero.com Previous smoker (quit 6 months ago) Takes traditional herbal teas Alternative dx: Gastritis History Finding(s) Physical Exam Finding(s) Chronic progressive worsening epigastric pain for about a year Epigastric tenderness on deep palpation without rebound tenderness or guarding Eating or drinking sometimes makes it better Eating spicy foods sometimes makes it worse Takes Ibuprofen (NSAIDs) for pain most days Denies hematemesis, hematochezia, or melena stools Denies dysphagia, regurgitation Drinks alcohol occasionally Takes traditional herbal teas Alternative dx: Gastroesophageal Reflux Disease History Finding(s) Physical Exam Finding(s) Chronic progressive worsening epigastric pain for about a year Eating or drinking sometimes makes it better Eating spicy foods sometimes makes it worse Drinks alcohol occasionally Takes traditional herbal teas This study source was downloaded by 100000804629821 from CourseHero.com on 11-23-2021 20:12:14 GMT -06:00 https://www.coursehero.com/file/75500729/AQ4-Family-Medicine-19pdf/ This study resource was shared via CourseHero.com Previous smoker (quit 6 months ago) V. Explanation of Diagnostic Plan (including tests, labs, imaging studies, etc.) and Treatment Plan in prioritized order: Diagnostic Plan Rationale Serum Test for H. pylori antibodies This is used to confirm evidence of past infections with H. pylori Urea Breath Test Accurately detects active infection with H. pylori but it is more expensive than the serologic test and requires that patients stop taking their medications for about two weeks prior to performing the test Stool H. pylori antigen testing This is more accurate than antibody testing. Although less expensive than the urea breath test, it is however more expensive than the serology test and is less convenient. Upper endoscopy Endoscopy is the most accurate diagnostic test for peptic ulcer disease. The sensitivity of upper endoscopy in the detection of gastroduodenal lesions is approximately 90 percent but varies based on the location of the ulcer and the experience of the endoscopist. It is only indicated for patients older than 60 years or those with alarm symptoms (hematemesis, hematochezia, iron deficiency anemia among other symptoms) or for those who have been taking medications without any improvement. This study source was downloaded by 100000804629821 from CourseHero.com on 11-23-2021 20:12:14 GMT -06:00 https://www.coursehero.com/file/75500729/AQ4-Family-Medicine-19pdf/ This study resource was shared via CourseHero.com Treatment Plan Rationale Encourage patient to stop taking NSAIDs unless medically indicated NSAIDs can injure the gastric and duodenal mucosa leading to considerable morbidity and mortality Advice patient to avoid alcohol, coffee, and other caffeinated beverages They tend to stimulate acid secretion and may worsen the symptoms Advice patient to continue abstinence from smoking Smoking decreases vascularity to the gastric mucosal cells which can result in poor healing after an injury which is worsened using NSAIDs and H. pylori infection Empiric treatment: 1. PPI (Esomeprazole 40 mg daily) 2. Antacids This is the first-line therapy and should be used only if the patient is symptomatic and usually as needed. 1. The PPIs inhibit the parietal cell hydrogenpotassium adenosine triphosphate (ATPase) which mediates the secretion of hydrogen ions. They have been known to heal about 90% of ulcers but there is a danger of the prevention of absorption of Vit B12 and Iron. 2. The Antacids are used mainly for symptomatic relieve as they rapidly neutralize acid and are less expensive and easily tolerated. Triple therapy for H. pylori infection (10 – 14 days): 1. PPI (Esomeprazole/Nexium 40mg) once daily 2. Amoxicillin 1 g twice daily 3. Clarithromycin 500 mg twice daily This treatment is the initial treatment especially in patients with suspected or diagnosed H. pylori infection with the need for the eradication of the infection. This study source was downloaded by 100000804629821 from CourseHero.com on 11-23-2021 20:12:14 GMT -06:00 https://www.coursehero.com/file/75500729/AQ4-Family-Medicine-19pdf/ This study resource was shared via CourseHero.com Follow-up in 2 weeks This is important if symptoms have recurred or persisted Referral to GI for upper endoscopy This is required if after treatment there is still no improvement or there has been a progression of symptoms. Referral for Surgery This may only be indicated as a last option when there is brisk bleeding of about 6 – 8 units of blood within a 24 hours period or in case of recurrent bleeding, perforation, obstruction of the gastric outlet and refusal of a benign ulcer to heal despite treatment. References Cash, J. C., & Glass, C. A. (2017). Family Practice Guidelines (4th ed.). Springer Publishing. Dunphy, L. M. H., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care: the art and science of advanced practice nursing. F.A. Davis Company. Longstreth, G., & Lacy, B. (2020). Approach to the adult with dyspepsia. UpToDate. https://www.uptodate.com/contents/approach-to-the-adult-withdyspepsia?search=epigastric+abdominal+pain. I have adhered to the honor system: This study source was downloaded by 100000804629821 from CourseHero.com on 11-23-2021 20:12:14 GMT -06:00 https://www.coursehero.com/file/75500729/AQ4-Family-Medicine-19pdf/ This study resource was shared via CourseHero.com Powered by TCPDF (www.tcpdf.org)