NR 511 Week 5 iHuman Virtual Patient Encounter Attempt 2517019 - Vijay Rao

History Notecard by Jessica Szymanski on case Vijay Rao Use this worksheet to organize your thoughts before developing a differential diagnosis list. 1. Indicate key symptoms (Sx) you have identified from the history. Start with the patient's reason(s) for the encounter and add additional symptoms obtained from further questioning. 2. Characterize the attributes of each symptom using "OLDCARTS". Capture the details in the appropriate column and row. 3. Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider the patient's age and risk factors.) Use your ideas to help guide your physical examination in the next section of the case. HPI Sx = abdominal Sx = weight Sx = Sx = black pain loss heartburn stools Onset 6-8 months ago past few unknown, 3 weeks months chronic ago Location epigatric, generalized chest, stool sometimes epigastric radiates to back Duration ongoing, usually ongoing ongoing, twice in happens an hour chronic 3 weeks after eating, pain comes and goes Characteristics awakens him at poor "worse than black tarry night, feels like appetite, usual" stool, burning, does not "stinky" occasionally stabbing feellike eating much Aggravating more often after unknown unknown unknown he drinks beer Relieving TUMS, not unknown TUMS unknown eating, not drinking beer Timing / Antacids used to unknown antacids unknown Treatments help the pain but lately are not working as well Severity Severe, Mild, Moderate, Moderate, This patient is very patient not to patient for GI concerned very bleed concerned Attempt: 2517019 Report generated on 9/27/2022, 4:14:23 PM America/Denver Management Plan by Jessica Szymanski on case Vijay Rao Subjective: abdominal pain started 2-3 months ago rated 7/10, in the epigastric area. It awakens him at night, more often after he drinks beer and usually happens an hour after eating. It feels like burning, occasionally stabbing, pain comes and goes, and he does not eat as much d/t the pain and feels full sooner than normal. Antacids used to help the pain but lately are not working as well. He reports new black, tarry, “stinky” stools that have occurred twice in 3 weeks, weight loss 10 lbs over 3 months, and heartburn that is worsening, aggravated by alcohol. He also reports increased fatigue, increased alcohol consumption since retirement, and bilateral knee pain resulting in increased NSAID use. Objective: In the clinic he is tachycardic, HR 110-120, conjunctiva are pale, and epigastric area is tender on palpation, and he has dark black guaiac positive stool. Diagnostics: BMP (normal), abdominal US (normal), CBC (hgb 10, htc 30), EGD (+ stomach ulcer), lipase (normal), LFT (normal), stomach biopsy (- malignancy, + H. pylori) Assessment: Peptic ulcer disease (PUD) r/t H. pylori is the final diagnosis. The diagnosis of peptic ulcer disease (PUD) is supported by the risk factors of alcohol use, smoking, and use of NSAIDS with the classic presentation of food-provoking increase in pain. The ulcers can intermittently bleed resulting in anemia that present as fatigue, conjunctival pallor and tachycardia. Plan: Stop NSAIDS and treat with omeprazole (Prilosec)