Week 5 Aquifer Case Study

Sample Answer

Week 5 Case Study

The case study considered for this discussion is a thirty-nine-year-old male who presents with epigastric pain. A history, physical exams, and assessment for the aquifer virtual case were completed. Therefore, various domains are answered as shown below.

History

Various questions were asked to help reveal what the patient could be suffering from. However, there are additional questions that were not asked but should be asked for better assessment. One of the questions should inquire about if the patient has had any changes in appetite in recent times. The other question that was not asked but could have been asked is the patient’s nature of pain (Tosetti et al.,2021). Even though he states that he has epigastric pain every day, it is important to know if the patient comes and goes or if it is constant.

The rationale for asking about the recent changes in appetite was to help explore various options such as vomiting, nausea, or indigestion. The change in appetite can also be connected to eating habits and, eventually, the pain the patient experiences. Asking about the nature of pain would be key to narrowing down the possible cause of the problem, as abdominal pain is a common cause of hospital visits (Tosetti et al.,2021).

There are also additional questions that might reveal about the patient’s health. One of them is if the patient has experienced a change in weight in recent times. The other question is whether the pain is relieved through rest and worsens with exertion

Physical Exams

The provider examined each system for various reasons. The provider assessed each system with the major focus of getting the baseline information and establishing the most likely diagnosis, which can then lead to the formulation of a good treatment and management plan

Based on the information in this case, there are exam findings that would be considered abnormal. One of them is discomfort in the chest and pain that moves towards that shoulder. Another abnormal finding would be chills, swelling, and abdominal swellings, which could point to various gastrointestinal conditions such as GERD. If it was a wellness visit, then abnormal findings would include hematuria and reduced rates of urination, which could point to conditions such as cystitis

There are also various findings that could be considered normal for each system.
General The patient is expected to be free of anxiety and no weight gain. HEENT The patient is expected to have normal conjunctiva, no masses, no enlarged thyroids. Lungs The lungs are expected to be resonant and clear in every area. Heart Both S2 and S1 are expected to be audible. Abdomen The abdomen is expected to have no masses or tenderness. It should also have normal sounds. Gastrointestinal No watery stools and no nausea expected. Genitourinary It is expected that the patient will have no pain when urinating. Musculoskeletal No pain is expected.

There are also various diagnostic instruments that would be needed to examine the patient. They include endoscope and stethoscope

Assessment (Medical Diagnosis)

The diagnosis for this patient is Peptic ulcer disease (ICD code 27.1)-This is a condition that results from H. pylori bacteria as well as the use of other medications such as ibuprofen (Bereda, 2022). The patient has been using the medication and also works in an environment that may expose him to the condition. The condition’s pathophysiological process entails the action of cytokines, which eventually injures gastric mucosa. The end result is enhanced gastric secretions, which cause damage to the stomach linings

Differential diagnosis

Gastritis (K29.70)-This condition which causes stomach lining inflammation. The pathophysiology of this condition entails a continuous mucosal injury resulting from H.pylori infection. Such an event then causes mucosa erosion, which then leads to glandular cell damage (Kishikawa et al.,2020).

GERD This is a condition that is known to be caused by factors such as diet, smoking, stress, and excessive weight gain. It usually occurs when there is a flow back of the stomach acid to the esophagus, which then irritates the esophagus lining (Maret-Ouda et al.,2020). Some of the symptoms point to this condition

Laboratory and Diagnostic Tests

There are various labs that should be ordered in this case. They include tests done using endoscopy urea breath test for H. Pylori and H. Pylori IgG to reveal antibodies (Darma et al.,2019).

There are various lab results that would be considered abnormal. For example, a positive test obtained for the urea breath test and H. Pylori IgG (Darma et al.,2019)

The abnormal lab values would be indicative of various things. For example, positive lab findings would show that H. Pylori inversion exists. Additionally, the H. Pylori IgG would indicate that there was a previous infection. The urea breath test would also show that the patient has an infection, and it can be more effective since it is shown from breath.

There are also diagnostic procedures that I might want to order based on the diagnosis. The diagnostic procedures include fluid status, kidney function test, ABG for any internal bleeding, and CBC

References

• Bereda, G. (2022). Peptic Ulcer disease definition, pathophysiology, and treatment. Journal of Biomedical and Biological Sciences, 1(2), 1–10. https //snipub.com/wp-content/uploads/2022/03/SNI-JBBS-22-02.pdf
  Darma, A., Nugroho, B. S. T., Yoanna, V., Sulistyani, I., Athiyyah, A. F., Ranuh, R. G., & Sudarmo, S. M. (2019). Comparison of Helicobacter pylori stool antigen, salivary IgG, serum IgG, and serum IgM as diagnostic markers of H. pylori infection in children. Iranian Journal of Microbiology, 11(3), 206. https //www.ncbi.nlm.nih.gov/pmc/articles/PMC6711868/
  
• Kishikawa, H., Ojiro, K., Nakamura, K., Katayama, T., Arahata, K., Takarabe, S., … & Nishida, J. (2020). Previous Helicobacter pylori infection–induced atrophic gastritis A distinct disease entity in an understudied population without a history of eradication. Helicobacter, 25(1), e12669. https //doi.org/10.1111/hel.12669
  Maret-Ouda, J., Markar, S. R., & Lagergren, J. (2020). Gastroesophageal reflux disease a review. Jama, 324(24), 2536-2547.
  
• Tosetti, C., Savarino, E., Benedetto, E., De Bastiani, R., & Study Group for the Evaluation of GERD Triggering Foods Alessandra Belvedere Carmelo Cottone Patrizia Gambaro Maurizio Mancuso Enzo Pirrotta Riccardo Scoglio Enzo Ubaldi Maria Zamparella. (2021). Elimination of dietary triggers is successful in treating symptoms of gastroesophageal reflux disease. Digestive Diseases and Sciences, 66, 1565-1571. Doi 10.1007/s10620-020-06414-z