Mr Rodriguez history pertinent to GIT
For the past year, Mr Rodriguez, a 39-year-old Latino, has been presenting to the emergency room with acute epigastric upper discomfort. He says that the discomfort is intermittent and every day and is accompanied by a retrosternal burning feeling in the upper epigastrium. He says that spicy meals aggravate the discomfort, which is alleviated by drinking milk. Poor appetite, severe weight loss, indigestion, bloating, and food loss are not linked to pain. Obstipation, diarrhoea, constipation, heavy black tarry stools, or dry intestinal heaves are all things he resists. He has a history of smoking, but claims to have quit six months ago, drinks two to three beers per week, and refuses to use any more drugs. According to his family history, his father had hypertension; his mother had diabetes. His other siblings have also survived. He dismisses any past hospitalizations or diseases. The patient is now on PRN ibuprofen for stomach discomfort and consumes Yerba herbal tea; however, none of these treatments alleviates symptoms. He has not had any known drug responses.
The test will begin with a physical assessment of his vital signs. The temperature is 97.6 degrees Fahrenheit, the pulse rate is average at 70 beats per minute, the respiratory rate is 16 breaths per minute, and the blood pressure is 140/90 mmHg. The patient seems unwell and has a forward-leaning stride due to stomach discomfort. He is drowsy, anxious, and in pain, yet he is aware of his surroundings, people, and time. The gastrointestinal tract was examined and found free of jaundice, pallor, cyanosis, central and peripheral oedema, and dehydration. There are no visible scars, lumps, or colour abnormalities in the skin on the abdominal inspection. On auscultation, there are more minor intestinal sounds. Percussion has neither a dullness nor an elastic excitement. It is favourable for epigastric discomfort on light and deep palpation but harmful for abdominal masses and no improvement in local temperature. Additional stool microscopy and H. pylori antigen testing should be done.
Differential diagnosis and diagnosis
Gastritis, GERD, and PUD are all-important differential diagnoses. Gastritis is a condition in which the healthy stomach lining becomes inflamed. Nausea, vomiting, upper abdominal fullness, and indigestion are other common side effects (Lanas & Chan, 2017). H. Pylori infection is the primary cause, but excessive drinking and smoking and long-term use of NSAIDs are also factors. Chest discomfort, a burning sensation known as heartburn, difficulty swallowing, food regurgitation or a sour liquid, and lumps in the throat are all common symptoms of GERD. Upper abdomen discomfort, decreased appetite, significant weight loss, and belching are all symptoms of PUD (Lanas & Chan, 2017). Other factors are excessive smoking, alcohol use, Helicobacter pylori infection, and long-term use of NSAIDs. Using diagnostic tests to confirm the diagnosis of stomach ulcers, these differential diseases may be ruled out more quickly. Endoscopy and barium swallowing can be used as diagnostic tools for stomach ulcers.
Mr Rodriquez’s treatment strategy would necessitate a change in pharmaceutical management and lifestyle. Pharmacological medication, such as omeprazole, ranitidine, and metronidazole, can be utilized to offer relief from infection, especially in the case of positive H. pylori (Sverdén, Agréus, Dunn & Lagergren, 2019). He will also be cautioned against quitting smoking altogether and abstaining from alcohol usage. The use of alcohol and tobacco increases the stress factors linked to the formation of stomach ulcers and lowers the stomach linings’ immunity to infections like Helicobacter pylori (Sverdén, Agréus, Dunn & Lagergren, 2019). He will receive more health instruction on diet adjustment, as he is to avoid hot meals and items that cause gastrointestinal pain. Additional instruction will avoid stress and live a depressing lifestyle since these factors can weaken immunity and worsen illness symptoms.