Use the following template to complete your answers to this case study and resubmit via tigermail on or before the due date.

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1 Case Study # 1 ADULT CASE STUDY Use the following template to complete your answers to this case study and resubmit via tigermail on or before the due date. SCENARIO Ralph Turner is a 35-year-old Caucasian male who presents with severe sharp LUQ abdominal pain associated with nausea and vomiting. He states that the pain started approximately 2 days ago after eating chili. The pain seems to come on as a spasm/cramping that is quite sharp then either goes away or turns into a burning sensation that goes to the chest. He states that over the past 7 years he has taken antacids for indigestion, and it does offer some relief. He is accompanied to the clinic by his girlfriend. TENTATIVE DIAGNOSES Based on the information provided so far, what are the potential diagnoses? Potential Diagnosis Gastric cancer Peptic Ulcer Disease (PUD) Angina Cholecystitis Pancreatitis GERD Other Provide rationale to support for each potential diagnosis based on information provided above Patient has symptoms consistent with heartburn and also has abdominal pain. With gastric malignancy nausea, vomiting are frequently present PUD is often described as a burning sensation. Pain is usually worse after eating. With PUD antacids offer relief. Nausea is also associated with. Patients with Angina have chest pain. It is described as a sharp stabbing pain. Patient normally has nausea and vomiting. Pain comes and goes. Abdominal pain present Patients does have nausea and vomiting along with abdominal pain It is often relieved by antacids. Pain is usually after meals. It is usually in the upper abdomen. Nausea and vomiting are frequently present and pain is described as a burning in chest. HISTORY Below is the history obtained from Ralph. What are the significant findings that will help you narrow down to a specific diagnosis for Ralph? Requested Data Allergies Data Answer NKDA 1

2 Current Medications Advil/Tylenol prn Mylanta 1-2 tablespoons every 3-4 hours Fluoxetine (Prozac) 20 mg OD Laxative as needed Surgery/Transfusions Appendectomy at age 14 PMH including: hospitalizations/fractures/injuries/accidents Immunizations Appetite/wt. loss/gain 24-hour diet recall Relationship of indigestion/abdominal pain to eating Depression and decreased ability to control anger Gastritis Measles Chicken pox TB last year negative Tetanus 6 years ago Spontaneous wt. loss of 10# in last 3 wks B: Cold cereal and coffee L: Sandwich, tuna, with a beer D: Mexican food with beer Usually symptoms start right after eating. If he relaxes/rests after eating the symptoms do not seem to be as bad. Sleeping No problem falling asleep. Usually sleeps 6 hours. Sometimes has indigestions at night that is relieved with antacids Social history Family History Relationship with family Home Last complete PE Income/insurance Tobacco: 1 ½ ppd Alcohol: a case of beer/day that is shared with friends Caffeine: 7-8 cups of coffee or soda/day Drugs: only OTC s Exercise: rarely Father: Alive, 61, unsure of health, history of alcohol abuse Mother: Deceased from stroke at age 59 Siblings: 2 sisters, one in good health, one with psychiatric problems. 1 brother, healthy Has girlfriend. She recently had a baby. He finds this very stressful since he is unemployed and has not income except for working on cars in the neighborhood. Lost his job about 3 months ago. Feels like all he and his girlfriend do now is shout at each other. Live in a one-bedroom apartment with girlfriend and infant 2 years ago when he started a new job Makes about $1,200/month as an off the books mechanic and odd jobs around the neighborhood. Lost health insurance when he lost his job. 2

3 Depression history: How do you usually handle stress? Have you ever though of harming yourself? Describe how you feel now Strike out at those around me No I feel sad, down in the dumps, and I want to get a job. REVIEW OF SYMPTOMS Below are key points of ROS SYSTEM REVIEWED General GI GU Lungs Cardiac DATA ANSWER No acute distress but expresses feeling stressed and unhealthy Denies black, tarry, or bloody stools or emesis. Occasional constipation Denies problems with urinating, burning, frequency, or emptying his bladder Denies SOB except when going up lots of steps or carrying the baby. Has a morning smoker s cough Denies sweating, radiation of pain to arm or neck. No SOB or palpitations PHYSICAL EXAM Significant portions of PE based on Ralph s complaints SYSTEM FINDINGS Vital signs b/p: 110/70 HR: 96; RR: 28; T: 97.8 Ht ; Weight 175# General appearance Neatly dressed, well developed, anxious. Hair thinning, pale in color. Turgor fair, no jaundice Mouth Lips dry, cracked, oral mucous membranes pale pink, tongue dry and tender to touch Lungs Clear to auscultation in all fields Heart Clear S1 and S2, HRR, No murmurs, clicks, or gallops Abdomen 5cm well healed scar RLQ. No venous distention or striae. Symmetrical without obvious bulging. No visible peristaltic waves. High pitched, 3

4 Rectum hyperactive bowel sounds, no bruits or venous hums. Liver percussed 13 cm MCL. c/o tenderness in epigastric area. Neg. Murphy s sign, psoas, and rebound. Small noninflammed external hemorrhoids. No rashes or irritation. No tenderness on palpation. Normal sphincter function. Prostate smooth. No masses. Hard brown stool, guaiac negative. DIFFERENTIAL DIAGNOSES Provide the significant positive and negative data that support or refute your diagnoses for Ralph. DIAGNOSIS POSITIVE DATA NEGATIVE DATA Gastric Cancer Patient has symptoms consistent with heartburn and also has abdominal pain. With gastric malignancy nausea, vomiting are frequently present. Weight loss is frequently present PUD Angina Cholecystitis Pancreatitis GERD PUD is often described as a burning sensation. Pain is usually worse after eating. With PUD antacids offer relief. Nausea is also associated with. Patients with Angina have chest pain. It is described as a sharp stabbing pain Often have nausea and vomiting Patients does have nausea and vomiting with. It is often relieved by antacids. Pain is usually after meals. It is usually in the upper abdomen. Nausea and vomiting are frequently present and pain Abdominal pain is usually mild Pain normally radiated to the back Patient does not have shortness of breath or fever Usually in right upper quadrant. They usually have a fever Pain radiates to the back and fever is frequently present. Patient does not have respiratory symptoms that are frequently associated with GERD 4

5 Other is described as a burning in chest. DIAGNOSTIC TESTS Based on the history and PE the following diagnostic tests were ordered. The test and results are provided. You will need to provide a rationale to support the use of this test for Ralph or provide documentation why you would not order this diagnostic test in this case. DIAGNOSTIC TEST RESULTS RATIONALE CBC with diff RBC: 4.21 WBC: 6.6 Hbg: 13.2 Hct: 39.1 MCV: 92.8 With Ralph having abdominal pain, a CBC is a good idea to rule out an infectious process. Also important to know Hemoglobin and Hematocrit to make sure no blood loss Albumin 3.2g/dl An Albumin will tell us about the patients nutritional status. This would be helpful considering his weight loss. A low albumin level is also indicative of liver disease. The patient has pain in abdomen. Electrolytes, LFT s, Renal studies NA: 137 K+: 4.2 Cl: 97 CO2: 35 BUN: 8 Creat: 0.7 AST: 51 ALT: 75 Alk Phos: 120 H. Pylori Serum: H. pylori + Breath test: + Abdominal X-ray No evidence of bowel obstruction, no evidence Given the pain in abdomen and his weight lose, it would be great to decide if he is dehydrated. Also evaluating his liver enzymes with abd pain H. Pylori causes pain in the abdomen and nausea is also associated with it. It is often described as a burning pain. Severe abdominal pain warrants a abdominal 5

6 Upper GI series of free intraperitoneal air No evidence of reflux or obstruction xray to rule out bowel obstruction Patients symptoms are very consistent with reflux. This rules out reflux Endoscopy + CHOtest Yes, it confirms H. pylori and is the most reliable test for H. pylori and does not produce false positives Other test? DIAGNOSES Based on the data provided what are the appropriate diagnoses for Ralph? List all appropriate diagnoses for Ralph in priority order. H-Pylori Peptic ulcer disease depression anxiety THERAPEUTIC PLAN Provide answers with scientific basis for the following questions about Ralph s treatment plan. Provide APA references when indicated. 1.What factors contribute to gastric acidity? High amount of caffeine, Alcohol intake. His diet, he eats acidic foods. Tobacco is a trigger. Anxiety over lack of job and stress over new baby. Stress associated with fighting with Girlfiend, new baby and lack of a job (2) What are issues to consider when deciding on a treatment plan for Ralph s problems with gastric acidity? Cost, Ralph does not have a job and is already worried about money. His anxiety and depression are contributing to his problems with gastric acidity. So this needs to be addressed as well. Also, his diet is also contributing and should also be addressed. (3) What lifestyle changes would you recommend for Ralph to help with the diagnoses you identified? 6

7 Stop alcohol use. Limit or stop caffeine. Smoking cessation Decrease or stop acidic foods. Deep breathing exercises for stress. Expressing feelings for depression. Start on a bland starchy diet with low acid (4) What are the pharmacological treatments that are evidence-based to treat Ralph s GI complaints? Omeprazole 20 mg bid, Clarithromycin 500 mg BID and Amoxil 1000mg bid. Take all Medication for 14 days (5) What side effects can Ralph expect from the pharmacological treatment plan? Possible abdominal pain or diarrhea from Antibiotic. Nausea, metallic taste, skin rash, or vomiting (6) What suggestions would you make for Ralph and/or his family related to stress reduction? Deep breathing exercises. Patient needs to talk about feelings. Possible counseling. Exercise daily. Take depression medication as prescribed (7) What education should be provided for Ralph prior to leaving the clinic? Should tell him the importance of taking medication as prescribed. He should also be told of the importance of following up. He should be educated on the fact that his lifestyle which has not caused the h. pylori but will make his symptoms worse and changes are recommended. Good hand washing. (8) What prevention strategies for family members should be discusses? Good handwashing. Lifestyle changes such as smoking cessation, reduce alcohol, decrease caffeine. Telling the family will help with compliance. Good handwashing to stop the spread of H. pylori (9) What would be the follow-up plan for Ralph? Consider perfoming a UBT 4-12 weeks after treatment (10) Is there any additional information that you feel needs to be provided for Ralph and/or his family prior to concluding this office visit? Make sure you take all of your medications and take them as prescribed Follow up sooner if needed or if any new or worsening of symptoms. Handwashing 7

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