A 48-year-old male complains of severe epigastric pain that is worse after eating x 3 weeks. Symptoms are accompanied by nausea but patient denies vomiting or diarrhea at this time. Reports stools as “normal” in color and consistency.

A 48-year-old male complains of severe epigastric pain that is worse after eating x 3 weeks. Symptoms are accompanied by nausea but patient denies vomiting or diarrhea at this time. Reports stools as “normal” in color and consistency.

A 48-year-old male complains of severe epigastric pain that is worse after eating x 3 weeks. Symptoms are accompanied by nausea but patient denies vomiting or diarrhea at this time. Reports stools as “normal” in color and consistency.

Week 2 680 B: Epigastric Pain

CC: A 48-year-old male patient presents to the clinic with a chief complaint of severe epigastric pain. He claims that the pain started 3 weeks ago and worsen when eating.  Associated symptoms include nausea, but the patient denies diarrhea or vomiting at the moment. The patient also reports normal stool in terms of color and consistency.

Physical Examination:

During the physical examination, the patient will be asked additional questions such as whether she has been able to see a medical provider in the past for similar symptoms, the severity of the pain on a pain scale of 0-10, whether the pain radiates to the back, arm or chest and if he has taken any medication to manage the pain. It is also important to ask the patient about his family history, history of surgery, social history, and health maintenance.

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Subjective:

General: Check for signs of fatigue and weakness.

Allergies: No food, drug, or environmental allergies were reported.

HEET: Head: No signs of trauma. Eyes: No pain, pressure, vision changes or photophobia. Throat: No swallowing difficulties, or hoarseness.

Respiratory: No wheezing, dyspnea, or cough.

Cardiovascular: No chest pressure, irregular heart rate, or palpitations.

Abdominal: Confirms severe epigastric pain accompanied by nausea for the past 3 weeks. No diarrhea or vomiting at the moment. Normal stool color and consistency were reported. check for any changes in the patient’s appetite.

GU: No pain, burning sensation, increased frequency, or difficulties when urinating.

Musculoskeletal: No muscle or joint pain. Exhibit full range of movement in both upper and lower limbs.

Neurological: No behavioral changes or trouble with concentration reported. No motor-sensory loss, sleep disturbance, seizures, or fainting.

Surgical History: Ask the patient if he has ever undergone any kind of surgery in the past.

Objective:

Since no objective data has been provided regarding the assigned case study, it is necessary to complete a physical assessment to gather the following information:

General: vital signs to check for hypotension and tachycardia in case the patient’s pain is associated with internal bleeding. The patient’s BMI must also be obtained. Assess for mental distress.

Skin: check for skin rashes, irritations, redness, and skin turgor for hydration.

HEET: Head: check if the head is normocephalic in appearance and any signs of trauma. Eyes: check whether the EOMs are present bilaterally. Ears: Check for discharge or drainage. Throat/Mouth: check for tonsils, and trachea deviation.

Respiratory: Check if the chest expands symmetrically; assess the lung sounds in all fields A&P, and check for breathing sounds through auscultation for signs of crackles/rales, wheezes, or rhonchi. Also, check the rhythm of respiration.

Cardiovascular: Assess the patient’s heart rate and rhythm. Check for gallop, rubs, clicks, or murmurs by auscultation.

GI: Inspect the patient for abdominal nodules, pulsation of the aorta, skin discoloration, masses, lesions, or scars. Assess the abdominal sounds in all four quadrants. Check for the location and severity of the tenderness by palpating all four quadrants. Percuss all the four abdominal quadrants to distinguish between high-pitched sounds that indicate gas and dull sounds that indicate accumulation of fluids. Also assess for rigidity, hepatomegaly, splenomegaly, and distention.

GU: check for any changes in urination pattern, the color of urine, frequency, urgency, or any associated pain.

Musculoskeletal: Check if the patient can exhibit ROM. Assess for muscle strength, pain, and rigidity.

Neurological: assess the patient for visual disturbances and headaches.

Diagnostics:

Blood test: monitor the patient’s HCT/HGB counts for signs of internal bleeding. White blood cell count can also help assess the presence of an infection (Lukic et al., 2022).

Urea breath test: To determine whether the patient is positive for H. pylori for peptic ulcer disease (PUD) diagnosis (Zhang et al., 2020).

Stool test: To assess for the presence of any microorganism which might be contributing to patients’ symptoms.

Upper GI biopsy and endoscopy: to check for tissue abnormalities or signs of the duodenal, stomach, and esophageal ulcers.

CT scan: To change for any changes in the anatomical structure of the abdomen.

Assessment

Differential Diagnoses:

1. Peptic ulcer disease (PUD): The patient is positive for severe epigastric pain which worsens when eating and is associated with nausea which are the main indications of PUD because of increased stomach acid (Khan & Singh, 2021). However, to confirm this diagnosis, a urea breath test and stool tests are needed to identify the presence of H. pylori as mentioned earlier.
2. Gastroesophageal reflux disease (GERD): This is a digestive disease that occurs when gastric acid flows back and irritates the food pipe lining (Katzka & Kahrilas, 2020). Patients present with burning pain around the chest area which normally worsens when eating or lying downs. The patient is positive for these symptoms. However, upper GI endoscopy is required to confirm this diagnosis.
3. Hiatal hernia: It occurs when the upper part of the patient’s stomach bulges into the chest area. Most of the time patient will present with no symptoms (Sfara & Dumitrascu, 2019). However, in severe cases, patients will report abdominal discomfort and heartburn. An X-ray of the Upper GI is needed to confirm this diagnosis.

Working Diagnosis: Peptic ulcer disease (PUD):

Plan:

Pharmacotherapy: With positive H. pylori results, clinical guidelines recommend the use of triple therapy regimen containing a proton pump inhibitor, amoxicillin, and clarithromycin for 7 to 14 days (Khan & Singh, 2021). Homeotherapy approaches such as Nux vomica can also help in managing abdominal disturbances such as indigestion and heartburn.

Diagnostics: Urea breath test, stool test, Upper GI biopsy, and endoscopy (Lukic et al., 2022).

Health Education and lifestyle changes: educate the patient on the need of completing the triple therapy to promote a positive care outcome (Zhang et al., 2020). The patient should also be advised on appropriate life modification approaches such as eating a diet rich in fiber, avoiding spicy foods, reducing stress levels, quit the use of alcohol or smoking.

Preventive care: To prevent such symptoms from occurring in the future, it is necessary to advise the patient to always consume foods containing flavonoids like garlic, eat lots of anti-oxidant-rich food, exercise regularly, and sleep for between 7 to 8 hours every night. The patient should also be advised to always be hydrated by drinking 6 to 8 glasses of water every day (Lukic et al., 2022).

Follow up: The patient should report back to the clinic after 1 to 2 weeks, upon completing the medication to determine whether the desired outcome has been achieved, or if there is a need for adjustment to be made in the care plan (Sfara & Dumitrascu, 2019).

References

Katzka, D. A., & Kahrilas, P. J. (2020). Advances in the diagnosis and management of gastroesophageal reflux disease. BMJ, 371. https://doi.org/10.1136/bmj.m3786

Khan, M. S., & Singh, V. (2021). Peptic Ulcer Disease (PUD): An overview of the History, Risk factors, Symptoms, Diagnosis Considerations, and Conventional Management. Asian Journal of Pharmaceutical Research and Development, 9(5), 111-114. https://doi.org/10.22270/ajprd.v9i5.1027

Lukic, S., Mijac, D., Filipovic, B., Sokic-Milutinovic, A., Tomasevic, R., Krstic, M., & Milosavljevic, T. (2022). Chronic Abdominal Pain: Gastroenterologist Approach. Digestive Diseases, 40(2), 181-186. https://doi.org/10.1159/000516977

Sfara, A., & Dumitrascu, D. L. (2019). The management of hiatal hernia: an update on diagnosis and treatment. Medicine and Pharmacy Reports, 92(4), 321. DOI: 10.15386/mpr-1323

Zhang, M. Y., Tan, N. D., Li, Y. W., Sifrim, D., Pandolfino, J. E., Xiao, Y. L., & Chen, M. H. (2020). Esophageal symptoms versus epigastric symptoms: Relevance for diagnosis of gastroesophageal reflux disease. Journal of Digestive Diseases, 21(12), 696-704. https://doi.org/10.1111/1751-2980.12946

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1. A 48-year old male complains of severe epigastric pain that is worse after eating x 3 weeks. Symptoms are accompanied by nausea but patient denies vomiting or diarrhea at this time. Reports stools as “normal” in color and consistency.
Possible diagnosis Gastroesophageal reflux (GERD)
Hiatal hernia, Peptic ulcer , cancer.
For the case you have chosen, post to the discussion:
• Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
• In SOAP format, list:
o Pertinent positive and negative information
o Differential and working diagnosis
o Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
Medication: Antacid
Proton Pump Inhibitors (PPIs)
Other test: Endoscopy, Upper gastrointestinal (barium swallow)