Today, you are working at a family medicine clinic with Dr. Medel. Together, you review her clinic schedule for the day and she suggests that you see Mr. Cesar Rodriguez, a 39-year-old male who recently moved to the U.S. from the Dominican Republic. This is Mr. Rodriguez’s first visit to the clinic. – PLEASE MENTIONED THAT A INTERPRETER WILL BE UTILIZED
Patient Name: Cesar Rodriguez
Age: 39
Sex assigned at birth: male
Gender identity: male
Pronouns: he/him/his
HPI: Mr. Rodriguez is a previously well 39-year-old Dominican immigrant who presents with chronic progressively worsening burning epigastric pain for one year. He reports no nausea, vomiting, regurgitation, hematochezia, melena, or consistent association with meals. He recently quit smoking, consumes alcohol and herbal teas occasionally, and takes NSAIDs frequently.
REVIEW OF SYSTEMS:
General: Reports no weight loss, fevers, chills, or night sweats.
GI: Reports no dysphagia, regurgitation, nausea, vomiting, anorexia, early satiety, hematemesis, hematochezia, melena, diarrhea, or constipation.
GU: Reports no dysuria, hematuria, or change in frequency.
CVS/Respiratory: Reports no chest pain, cough, or shortness of breath.
You ask Mr. Rodriguez a few more questions and discover that he works as a farm laborer. He has no known drug allergies. He smoked a few cigarettes daily but quit six months ago. He drinks three to four beers per week. He reports no other drug use. Aside from a move to the U.S. from the Dominican Republic 2 years ago, he has not traveled recently.You congratulate Mr. Rodriguez on quitting smoking and thank him for answering your questions. Mr. Rodriguez still seems a little anxious. Before you go to get Dr. Medel, you inquire – Mr. Rodriguez does not have insurance – social worker referral will be part of treatment plan.Differential for Chronic Progressively Worsening Upper Abdominal PainMost likely/Most important diagnoses
Functional Dyspepsia
Gastritis
sharp epigastric pain. This pain may be variably worsened or improved with eating food.
Inflammatory forms of gastritis may be caused by chronic infections, such as H. pylori, or acute infections, such as enterovirus.
Noninflammatory forms of “gastritis” are histologically termed gastropathy. These may be caused by chemical irritants to the stomach, including alcohol and medications.
GERD
symptoms commonly worsen after meals, although the pain is classically described as “burning” and is typically located in the substernal rather than epigastric area.
May be associated with regurgitation and, rarely, dysphagia.
Hematemesis in the setting of GERD-like symptoms is unusual and represents an alarming symptom warranting prompt GI referral for evaluation.
Nausea, vomiting, hematochezia, and melena are not typically associated with GERD.
Peptic ulcer disease(PUD)
Epigastric pain that improves with meals is the hallmark of PUD of the duodenum (DU). In PUD of the stomach (GU), symptoms characteristically worsen with meals.
NSAID use and H. pylori infections are associated with the development of PUD.
Hematemesis, if present, suggests a more complicated disease and warrants urgent GI referral.
Melena commonly occurs in the setting of an upper GI bleed secondary to PUD or hemorrhagic gastritis (e.g., NSAID-gastritis). Hematochezia occurs in the setting of an upper GI bleed only when massive (e.g., variceal rupture).
PHYSICAL EXAM:Vital signs:
Temperature is 36.9 C (98.5 F)
Pulse is 78 beats/minute, regular
Respiratory rate is 16 breaths/minute
Blood pressure is 123/72 mmHg
Body mass index is 24.8 kg/m2
General: Well-appearing male.
Head, eyes, ears, nose, and throat (HEENT): Sclera anicteric, no conjunctival pallor, oropharynx moist without lesions or dental erosions.Neck: Supple, no mass, lymphadenopathy, or thyromegaly.
Cardiovascular: Regular rate and rhythm, normal S1, and S2, no murmurs, rubs, or gallops.
Respiratory: Bilaterally clear to auscultation
Abdominal: Non-distended, symmetric appearance without scars or ecchymosis. Normoactive bowel sounds, no bruits. Normally scattered areas of tympany and dullness on percussion. Soft, with minimal epigastric tenderness on deep palpation without rebound tenderness or guarding, no hepatosplenomegaly, no herniae or masses.
Skin: No jaundice, no suspicious lesions.
Extremities: Warm and well-perfused, no cyanosis, clubbing, or edema.
INITIAL TREATMENT PLAN: A. Focusing on lifestyle modifications to promote symptomatic improvement B. Using an empiric treatment strategy with a proton pump inhibitor (PPI)
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FFUP IN 4 WEEKS; Mr. Rodriguez’s symptoms have not improved. You relate that the lack of improvement and the absence of classic symptoms of GERD are making you think GERD is an unlikely diagnosis. His past NSAID use makes you wonder if he more likely has gastritis or PUD, with or without H. pylori infection, although he could still have functional dyspepsia as well.
Vital signs:
Pulse is 80 beats/minute and regular
Blood pressure is 126/75 mmHg
Abdominal exam: Minimal epigastric tenderness is present without rebound or guarding, unchanged compared to his previous exam four weeks ago.
DIAGNOSTIC PLAN:
B. Order an H. pylori fecal antigen test
C. Order H. pylori IgG serology
D. Refer for a urease breath test
E. Send him home with a fecal occult blood test (FOBT)
——————————————————————————————————————————————————————-The next day, you and Dr. Medel are reviewing laboratory results. You notice that Mr. Rodriguez’s H. pylori IgG assay is positive: HELICOBACTER PYLORI IgG ANTIBODY BY EIAQUALITATIVEResult: POSITIVE
TREATMENT
First-Line Treatment for H. pylori
“Triple therapy” for 14 days:
PPI standard dose twice daily
Amoxicillin 1 g twice daily
Clarithromycin 500 mg twice daily
“Quadruple therapy” for 10 to 14 days:
PPI standard dose twice daily
Metronidazole 250 mg four times daily
Tetracycline 500 mg four times daily
Bismuth subsalicylate or subcitrate 300 mg four times daily
One alternative 10-day to 14-day triple regimen to consider in patients who are allergic to penicillin, in areas with low clarithromycin resistance, is:
PPI standard dose twice daily
Clarithromycin 500 mg twice daily
Metronidazole 500 mg twice daily
_________________________________________________________________________________________________FF UP: Mr. Rodriguez returns four weeks later. He states that his symptoms of dyspepsia initially improved somewhat after finishing the medication but have since recurred, occurring almost daily. He confirms he took all of the medication exactly as directed without side effects other than mild diarrhea and dark stools, which have resolved. Again, he reports no alarm symptoms. The FOBT that he did at home did not show blood.
Evaluation of Persistent Symptoms of DyspepsiaInvestigating H. pylori Eradication
The fecal antigen test and urea breath test are reasonable next steps to evaluate the eradication of H. pylori.
The fecal antigen test involves the collection of a small stool sample by the patient; the sample is then analyzed in a laboratory by trained personnel.
The urea breath test requires specialized equipment and patient preparation.
You obtain an H. pylori fecal antigen test for Mr. Rodriguez, which is positive. Through Lola, you explain to Mr. Rodriguez that the original medication regimen you gave him probably did not cure his H. pylori infection and that this happens 20% to 30% of the time.
Refer to a gastroenterologist for upper endoscopy/EGD with mucosal biopsy and H. pylori cultures
_________________________________________________________________________________________________.Mr. Rodriguez returns two weeks after the completion of salvage therapy for H. pylori gastritis. Through Lola, he tells you that he is completely symptom-free!
PLAN: A. Advisement to continue to minimize alcohol consumption
B. A follow-up appointment if symptoms of dyspepsia or any new symptoms recur
C. A follow-up appointment for a health maintenance examination
D. Positive reinforcement regarding smoking cessation
Essay Elements:
three pages of scholarly writing in paragraph format, not counting the title page or reference page
Brief introduction of the case
Identification of the main diagnosis with supporting rationale
Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out
Diagnostic plan with supporting rationale or references
A specific treatment plan supported by recent clinical guidelines
Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric.
