DISCUSSION 1

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

Student’s Name
Institutional Affiliation
Date
DISCUSSION 2

Patient History
The patient is 36 years old with abdominal pains which started several months ago. Mr.
Rodriquez when presented to the clinic reports that the abdominal pains started a yea ago. The
pain at first occurred only few times in a week, now the pain occurs daily together with a burning
sensation in epigastric region. He takes alcoholic beverages but has recently quit smoking. He
also uses NSAID, s frequently. The patient has no surgical, medical and family history. The
patient has a travel history from Dominican Republic to the U.S.
Physical Examination and Diagnostic tools
The vitals are within the normal limit. He looks anxious but well. Physical examination
will include; Palpation of nose, ears, eyes, neck and throat.it is to check for abnormalities.
Inspections and Auscultation of respiratory and cardiovascular system are normal. Skin and
extremities are normal, well perfused. The abdomen is tender, flat, non-distend, Hernia and
enlarged liver are noted. The epigastric region has deep palpation and minimal tenderness (Hunt
et.al., 2017).
From the initial diagnosis, the patient could be suffering from GERD. This can be
identified through empirical trial with PPI (Proton pump inhibitor) or H2RA (Histamin-2
receptor antagonist) up to four weeks. If the disease is GERD the symptoms will improve. After
four weeks we can do H. pylori IgG Serology test (Chey et.al.,2017). Since the patient has travel
history, it is a risk factor for H. Pylori, it could as be as a result of smoking cigarette (Leiman
et.al.,2017). If the initial treatment with PPI does not work Digital Rectal examination can be
done together with CBC test to check for anemia.
Possible Diagnoses
The Most likely differential diagnoses for the patient include; Peptic ulcers disease
(PUD), Gastritis and Gastroesophageal reflux disease (GERD). Gastritis cause irritation of the
stomach lining leading to a sharp epigastric pain. Patients who have a history of using NSAIDs
are likely to suffer from PUD. GERD is included among the diagnoses because it causes pain in
epigastric region. The correct diagnosis for the patient is GERD, which presents itself in the
epigastric region. The pain causes a burning sensation with absence of hematochezia, melena,
and hematemesis-this are the same symptoms on the patient.
Care plan Patient education and follow-up
Patient education is important for Mr. Rodriguez, since he is of Spanish origin, both
verbal education and written handouts should be included. The patient should be educated on the
importance ceasing to take aspirin and NSAIDs. The two are risk factors for ulcers and
gastrointestinal bleeding. He should be advising to use acetaminophen. Education should also be
centered on how to avoid smoking and limiting the intake of alcohol as this can lead to
gastrointestinal issues (Ozbey & Hanafiah, 2017). If the symptoms persist after treatment the
patient can be referred to a Gastrointestinal specialist for upper endoscopy to check for other
DISCUSSION 3

possible causes. Their vital signs for Gastrointestinal diseases which the patient should be aware
of such as; emesis, bloody stool, sticky, black and tarry stool (Hunt et.al., 2017).
The symptoms that were presented by our patient were resolved by salvage treatment.
The next step is to help the patient sign an insurance and closely followed with case
management. The patient should be encouraged to seek medical help anytime he sees new
symptoms or any cases of reinfection and other gastrointestinal symptoms.
DISCUSSION 4

References
Chey, W. D., Leontiadis, G. I., Howden, C. W., & Moss, S. F. (2017). ACG clinical guideline:
treatment of Helicobacter pylori infection. American Journal of
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https://journals.lww.com/ajg/Fulltext/2017/02000/ACG_Clinical_Guideline__Treatment_
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Leiman, D. A., Riff, B. P., Morgan, S., Metz, D. C., Falk, G. W., French, B., ... & Lewis, J. D.
(2017). Alginate therapy is effective treatment for GERD symptoms: a systematic review
and meta-analysis. Diseases of the Esophagus, 30(5), 1.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036656/
Ozbey, G., & Hanafiah, A. (2017). Epidemiology, diagnosis, and risk factors of Helicobacter
pylori infection in children. Euroasian Journal of Hepato-Gastroenterology, 7(1), 34.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5663771/
Hunt, R., Armstrong, D., Katelaris, P., Afihene, M., Bane, A., Bhatia, S., ... & LeMair, A.
(2017). World gastroenterology organisation global guidelines: GERD global
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