Family Medicine 19: 39-year-old male with epigastric pain, Quizzes of Nursing

Download Family Medicine 19: 39-year-old male with epigastric pain and more Quizzes Nursing in PDF only on Docsity! Family Medicine 19: 39-year-old male with epigastric pain The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes: Epidemiology and risk factors: 39-year-old previously well Latino immigrant. Key clinical findings about the present illness using qualifying adjectives and descriptive language: Chronic progressively worsening No vomiting, hematemesis, hematochezia, melena, or association with meals Quit smoking Occasional alcohol consumption Uses NSAIDs Uses traditional herbal teas Week 3 Gastrointestinal Discussion Discuss 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. Mr. Rodriguez’s chief complaint is abdominal pain. His history of present illness is abdominal pain that began a year ago and the abdominal pain occurred a few times a week, but now hurts every day. The patient reports burning in his epigastric area. His social history includes that he works as a farm laborer and reports a history of smoking cigarettes, drinking 3-4 beers a week, and denies drug use. Mr. Rodriguez reports that he quit smoking 6 months ago and says he has not traveled recently. The patient is a Latina immigrant who takes NSAIDs frequently and consumes herbal teas occasionally. The patient reports a family history of his father having hypertension and his mother having diabetes. The patient denies any medical problem except the existing stomach pain. The patient reports no known allergies. 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? The physical exam used for Mr. Rodriguez is a head-to-toe assessment. The provider also did a focused assessment of the abdomen. The diagnostic tool that was used was a basic review of symptoms and an assessment. The diagnostic test performed to diagnose the patient is an H. pylori fecal antigen test, H. pylori serology, urease breath test, and a fecal occult blood test. I believe it would be important for the patient to use a food diary to determine what foods cause improvement or worsening symptoms to see if modifying the patient’s lifestyle will bring about positive results. It would also be helpful to refer the patient for an upper endoscopy to rule out other significant GI diseases.