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? 

Mr. Rodriguez is a 39 year old male who recently moved to the United States from the Dominican Republic. He presents with a history with abdominal pain that has become increasing worse over the last several months, but began about a year ago. When the pain first started it occurred a few times a week and now he it occurs daily. He states that it is a burning pain and points to his epigastric region. He recently quit smoking and drinks 3-4 alcoholic drinks per week. He also reports using NSAID’s on most days of the week to deal with aches and pains from his work. Mr. Rodriguez denies surgical history, relevant family history (father has HTN and mother has Diabetes) or significant person medical history other than the abdominal pain (Heidelbaugh, n.d.).

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? 

Mr. Rodriguez’s physical exam appears to be normal except for the minimal tenderness to the epigastric region upon deep palpation.  His physical exam is below:

“Vital Signs:

Temperature: 98.5 Fahrenheit

Heart Rate: 78 beat/minute

Respiratory Rate: 15 breaths/minute

Blood Pressure: 123/72 mmHg

Body Mass Index: 24.8

General: Middle aged man that appears well but anxious.

Neck: Supple, no mass, lymphadenopathy or thyromegaly

Cardiovascular: Regular HR and rhythm, S1, S2, no murmurs, rubs or gallops.

Respiratory: Bilaterally clear lungs to auscultation without wheezes, rales or rhonchi.

Abdominal: Flat appearance without scars. Normoactive bowel sounds heard in four quadrants. Soft, non-distended, 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 (Heidelbaugh, n.d.).”

In this case study the suspected diagnosis is GERD, because of this diagnosis Mr. Rodriguez is placed on an empiric medication trial with proton pump inhibitor (PPI) for one month. He was also instructed to cut back on alcohol, caffeine, spicy foods, and ibuprofen and to substitute for acetaminophen instead when needed. At Mr. Rodriguez’s four week (one month) follow up he stated that “the medicine did not work even though he took it correctly” and that he still has a burning pain in his epigastric area. Since his treatment was not effective at that time other options for diagnoses were discussed. A H.pylori IgG serology test, CBC, digital rectal exam with guaiac-based fecal occult blood test are all done at that time.

“Vital Signs:

Heart Rate: 80 beats/minute

Blood Pressure: 126/75 mmHg

Abdominal Exam: He has minimal epigastric tenderness without rebound or guarding, which is unchanged compared to his previous exam four weeks ago.

Rectal Exam: Reveals a negative FOBT test, without any evidence of gross blood or anatomic abnormality.

H. pylori IgG Serology: Positive

CBC: Unremarkable for anemia (Heidelbaugh, n.d.).”

I would not have done any additional testing, however since Mr. Rodriguez recently moved to the United States and is from a country that H. pylori is prevalent I would have considered doing the h.pylori faecal antigen test at the first visit. “Although guidelines for the management of dyspepsia advocate a ‘test and treat’ policy for Helicobacter pylori (Elwyn et al., 2007)” the faecal antigen tests proves to be most cost effective and gives less false positives’ than the other two tests (breath test and serology). I understand that Mr. Rodriguez is worried about money since he does not have health insurance but I would have at least discussed this test with the supervising doctor because of his social history. 

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?

GERD- Mr. Rodriguez presents with epigastric pain that is sometimes worse after meals, especially spicy food that he described as a “burning” sensation. Mr. Rodriguez has no signs of hematemesis, hematochezia or melena which is consistent with GERD (Heidelbaugh, n.d.). 

Peptic Ulcer Disease (PUD) – Mr. Rodriguez presents with epigastric pain that sometimes improves after he eats but is sometimes worse after he eats. He also takes NSAID’s on a daily basis for aches and pains from work (Heidelbaugh, n.d.). 

Gastritis- Mr. Rodriguez presents with epigastric pain that is sometimes better and sometimes worse after eating food. He also has a history of daily NSAID use and admits to alcohol use which can sometimes irritate the stomach lining. He also recently moved from a country that has a higher prevalence for H. pylori that can cause inflammation and pain from irritation (Heidelbaugh, n.d.). 

The final diagnosis is Gastritis that was caused by a chronic H. pylori infection. This was discovered after a positive serology test and the PPI treatment was not effective after several weeks.

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?

Once Mr. Rodriguez was diagnosed with H. pylori he should be started on a triple therapy to treat the infection. The triple therapy treatment is a fourteen day regimen of a standard PPI dose twice a day, Amoxicillin 1 g twice a day, Clarithromycin 500 mg twice a day (Heidelbaugh, n.d.).