Assignent Solutionnurs

RESPONSE 1:
A 48-year-old male complains of severe epigastric pain that is worse after eating x 3 weeks. Symptoms are accompanied by nausea, but the patient denies vomiting or diarrhea at this time. Reports stools as “normal” in color and consistency.
Subjective
CC: Pt stated “I have severe epigastric pain after eating for the past 3 weeks”
HPI: The patient is a 48-year-old male who presents with a complaint of epigastric pain that began approximately 3 weeks ago. The patient states that the pain worsens with eating. He denies any fever, vomiting, or diarrhea. Normal stool and consistency. The patient admits to weekly NSAIDs usage and drinking 3-4 alcoholic beverages a week. He quit smoking 3 months ago. He drinks herbal tea but does not experience any relief or change in the symptoms.
PMH: no past medical and surgical history
Family Hx: no family history
MEDs: takes ibuprofen almost daily for back pain
Allergies: NKDA
Social history: the patient is a former smoker, who quit 3 months ago; The patient states that he drinks 3-4 beers weekly. No illicit drugs
Review of the systems (ROS):
Constitutional/General: the patient is alert and oriented. Afebrile. Denies fatigue and weakness.
EENT: denies double vision, no hearing loss, no ear infection
Cardiovascular: no chest pain, no syncope, no heart murmur, or palpitation
Respiratory: no SOB
Gastrointestinal: epigastric pain after meals, regular bowel movements, bloating, loss of appetite, nausea, but no emesis
Genitourinary: denies problem
Musculoskeletal: denies problem
Integumentary: denies problem
Neurological: no syncope, no seizure
Psychiatric: no anxiety, denies depression or mood swings. No suicide ideation
Allergy/Immunologic: NKDA. Denies frequent infections. Current with the flu vaccine
Objective
Physical Examination:
General:  A well-developed, well-nourished, and well-developed male who is alert and cooperative. He is a good historian and answers questions appropriately
Vital sign: BP 115/66; P 77; RR 20; T 98.6; O2 SAT 98% on RA
Skin: no lesion or rashes noted. Turgor is good. There is no cyanosis, pallor, or jaundice
HEENT: head normocephalic. Pupils are equal and reactive to light.  Wearing glasses. Oral mucosa pink and moist. No sinus tenderness
Respiratory: breath sound clear to auscultation in all lung fields, chest wall expansion symmetrical, no increased effort of breathing
Cardiovascular: heart regular rate and rhythm. No murmur, gallops, or rubs.
Abdomen: epigastric tenderness to palpation, no hematemesis, and melena. Stomach appears bloated
Musculoskeletal: Full ROM, no cyanosis, or edema
Neurological: alert, awake, and oriented x4, mood affect appropriate to the situation.
Psychiatry: no suicidal ideation or homicidal ideation
Questions:
Can you describe the pain? Does it radiate anywhere?
How long ago did your pain start?
Was the onset sudden or gradual?
How severe is the pain (on a scale of 1-10)?
Does the pain wake you up from sleep?
Is the pain getting worse or better since it started? What makes it worse or better?
When was your last bowel movement?
How frequent are your stool and what is the consistency?
Have you ever had this pain before?
Do you have nausea and vomiting?
Do you have blood in your stool?
Did you have unintentional weight loss?
Do you have chest pain, palpitation, fast heartbeat, or pain that goes to the arm or jaw?
Do you smoke? Do you drink alcohol? How much?
Do you have a family history of gastric cancer or peptic ulcer disease?
What medications are you taking?
(Dains, Baumann, and Scheibel, 2016)
Problem list/Assessment:
Epigastric pain after meals
Nausea and bloating
Alcohol and NSAID use
Negative fecal blood test
Acute Peptic Ulcer Disease K 27.3 (Working Diagnosis).
Pertinent positives are epigastric pain, nausea, bloating, pain presents after meals, chronic NSAID use, and alcohol use.
Peptic ulcers are open sores that develop on the inside lining of the stomach and the upper portion of the small intestine. Peptic ulcer includes gastric ulcers and duodenal ulcers. The most common causes of peptic ulcers are infections with bacterium helicobacter pylori (H. pylori) and long-term use of NSAIDs such as ibuprofen. Other risk factors may include smoking, which may increase the risk of peptic ulcers in people who are infected with H. pylori. Drinking alcohol can irritate and erode the mucous lining of the stomach increase the stomach acid that is produced and cause epigastric pain or heartburn. In gastric ulcers eating sometimes will make the pain worse, especially with spicy food. NSAIDs tend to cause inflammation of the GI tract lining. NSAIDs cause several changes within the stomach, including the reduced flow of blood to the stomach and less mucus production (Mayo Clinic, 2020).
Malignant Neoplasm of the Stomach C 15.9 (Differential Diagnosis)
Pertinent negatives – unexplained weight loss, reduced appetite, bloody stool
During the early stages, stomach or gastric cancer may not cause any symptoms, or may not be specific-like indigestion or stomach discomfort that does not go away. Since these symptoms mimic other, less serious conditions, many people may dismiss them. Early stomach cancer symptoms include indigestion, reduced appetite, heartburn, and mild nausea. Later symptoms may include dark or bloody stools, unexplained weight loss, excessive belching, vomiting, trouble swallowing, and feeling bloated. Other medical conditions, like peptic ulcers and gastritis, share these symptoms. If treated for these conditions and symptoms like bloating, heartburn or indigestion do not go away, further consultations to rule out stomach cancer are needed (City of Hope, 2021).
Acute Pancreatitis K 85 (Differential Diagnosis).
Pertinent negatives are anorexia, pain radiating to the back, fever, tachycardia, elevated lipase, or amylase
The patient with pancreatitis will commonly describe moderate to severe abdominal pain in the epigastric area with nausea and anorexia. A thorough history regarding alcohol use and medications should be gathered, keeping in mind that over five years of heavy alcohol use is often needed to include alcohol-related pancreatitis. Smoking history is also important as a risk factor for acute pancreatitis. A physical exam is often significant for elevated temperature, and tachycardia. The abdominal exam will reveal epigastric tenderness with possible guarding and rigidity and decreased bowel sounds (Gapp and Chandra, 2021).
Plan and Treatment
The patient’s clinical presentation suggests the diagnosis of peptic ulcer disease; therefore, the patient should be evaluated for alarm symptoms such as anemia, hematemesis, melena, or heme-positive stool which suggest bleeding; and for severe, radiating upper abdominal pain which suggests perforation; weight loss or anorexia might suggest cancer.  This patient does not present with alarm symptoms, he should be tested for H. Pylori infection and advised to discontinue the use of NSAIDs, smoking, and alcohol. The presence of H. Pylori can be confirmed with a serum enzyme-linked immunosorbent assay (ELISA), urea breath test, and antigen test.
If the test results are positive for H. Pylori, the infection should be eradicated and proton pump inhibitor over the counter such as Prilosec 20 mg two times daily or Prevacid 30 mg two times daily can be administered for four weeks, plus amoxicillin 1g two times daily and clarithromycin 500 mg two times daily can be administered. If the patient is negative for H. Pylori, we can order the proton pump inhibitors and do a follow-up. If the symptoms do not improve the patient should be referred to a gastroenterologist for endoscopy to rule out refractory ulcer and malignancy. Lab works such as CBC and liver function tests should be ordered to assess bleeding and elevated lipase or amylase (Johns Hopkins Medicine, 2021).
The patient can be advised to do a few lifestyle changes including the abstinence of alcohol and smoking and avoiding spicy and fatty foods. Stress may worsen peptic ulcer symptoms, learning how to cope with stress is also essential. 
RESPONSE 2:
Case Study #1: A 50-year-old female complains of being waken up at night with a bitter taste in her mouth about four times per week for the past two months. It is interfering with her sleep, and she is concerned.
Subjective:
CC: Patient states, “I keep being waken up at night with a bitter taste in my mouth about four times per week for the past two months and it is interfering with my sleep.”
HPI: 50-year-old female c/o being waken up at night with a bitter taste in her mouth about four times per week for the past two months. It is interfering with her sleep, and she is concerned.
PMH: denies health problems
MEDs: none
Allergies: NKA
Family Hx: none provided
Social Hx: Do you follow a particular diet and exercise regimen? Do you smoke or drink alcohol? Are you currently taking any medications or vitamins?
Review of Systems (ROS):
Constitutional/General – reports being woken up at night with a bitter taste in mouth about four times a week for the past two months, which is also interfering with her sleep.
Ears, Nose, Mouth & Throat – reports bitter taste in mouth. Denies blurred vision, hearing loss, ear pain, ringing in ears, or discharge. Denies a sore throat or hoarseness, difficulty swallowing, mouth sores, toothache, nosebleed, or nasal discharge.
Cardiac – denies chest pain, palpitations, orthopnea.
Respiratory – denies SOB, difficulty breathing at night, and cough.
GI – denies constipation, diarrhea, abdominal pain, nausea/vomiting, blood in stools, unexplained change in bowel habits.
GU – denies dysuria or urinary frequency.
Musculoskeletal – denies muscle pain, cramps, neck pain or stiffness, or changes in ROM.
Dermatologic – denies rash, itching, new skin lesion, abnormal nail or hair growth.
Neurologic – states difficulty sleeping at night. Denies numbness, tingling, paresthesia, or memory loss.
Psychiatric – denies suicidal ideation or depression.
Objective:
50-year-old female. Include vital signs, height, and weight. Patient’s appearance is defined in terms of posture, body movements, clothing, grooming, and hygiene. Level of consciousness, facial expression, speech, conversational speed, articulation, and word use are all examples of actions.
Questions:
When did you first notice the symptoms?
What were you doing when you first noticed the symptoms?
Do you encounter any other symptoms aside from bitter taste in mouth?
What makes it better or worse? Any particular triggers (positioning, activities, lying down, eating certain meals)?
Do you have any food allergies or intolerance?
Do you have a history of asthma?
Have you experienced this previously in the past?
Have you taken anything to relieve the symptoms (OTC or prescription)?
Assessment:
Working diagnosis: Gastro-esophageal reflux disease K21
Gastro-esophageal reflux disease (GERD) is a digestive disorder with symptoms and complications that result from the reflux of stomach contents into the esophagus. The most common symptom of GERD is heartburn which is associated with a sour/bitter taste in the back of the mouth with or without regurgitation, non-cardiac chest pain, hoarseness in voice, chronic cough, and disrupted sleep due to nighttime acid reflux (Clarett & Hachem, 2018).
Pertinent positive(s) – sour/bitter taste in mouth, disrupted sleep
Pertinent negative(s) – non-cardiac chest pain, cough, hoarseness in voice
Differential diagnosis: Hepatitis B B19.10
Hepatitis B is a viral infection of the liver with one of its early symptoms being bitter taste in the mouth along with other symptoms such as bad breath, loss of appetite, low-grade fever, nausea, vomiting, and diarrhea (Pietrangelo, 2019).
Pertinent positive(s) – bitter taste in mouth
Pertinent negative(s) – loss of appetite, low-grade fever, diarrhea
Plan:
Diagnostic tests:
Upper endoscopy to examine the inside of esophagus and stomach, and to collect a sample of tissue to test for Barrett’s esophagus.
Ambulatory acid (pH) probe test
Esophageal manometry testing
Barium radiography – although should not be used solely as a diagnostic test for GERD (Katz et al., 2022).
CBC, CMP, hepatitis panel
Referrals: GI for endoscopy and/or ambulatory pH testing
Discharge Instructions/Education: Lifestyle modifications to treat GERD include elevating head of bed by 6 to 8 inches, avoiding laying down 2 hours after meals, avoiding spicy foods, citrus, chocolate, peppermint, alcohol, tobacco, caffeine, carbonated beverages especially at evening meal to help reduce acidity (AAAAI, 2022). Maintain a healthy weight. Keep diary of signs/symptoms in relation to meals and activity. Monitor for alarming symptoms including bleeding, weight loss, dysphagia, and odynophagia (painful swallowing) which can detect presence of strictures, ulceration, and/or malignancy (Clarett & Hachem, 2018).
Follow-up: Return to clinic in 3-4 weeks or call/seek emergent care for worsening symptoms.
Medications:
OTC antacids can be used for on-demand symptom relief.
Mylanta 10-20 mL PRN, between or after meals, and at bedtime.
Tums extra strength 750 mg 2-4 tablets as symptoms occur, no more than 10 tablets in 24 hours.
Proton pump inhibitor (PPI) for frequent heartburn occurring 2 or more days a week.
Omeprazole (Prilosec) 20mg PO daily 30-60 minutes before first meal.
For maintenance therapy with PPIs, they should be administered in the lowest dose that effectively controls GERD symptoms (Katz et al., 2022).