NR 511 Week 5 iHuman Virtual Patient Encounter Attempt 2559832 - Nolan Young

History Notecard by Amber Quinn on case Nolan Young 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 = Sx = Sx = Sx = Sx = Sx = Onset Location Duration Characteristics Aggravating Relieving Timing / Treatments Severity Attempt: 2559832 Report generated on 11/27/2022, 2:07:08 PM America/Denver Management Plan by Amber Quinn on case Nolan Young Diagnostic Test ABD U/S: Normal liver, ultrasound spleen, kidneys, and pancreas BMP: Normal CBC: Hgb-10, Microcytic anemia probably due to iron deficiency from chronic GI bleeding. EGD: Mild esophageal irritation, probably secondary to reflux disease. Gastric ulcer noted close to the pylorus - probably benign but cannot rule out malignancy without biopsy. Lipase: Normal LFT: Normal Stomach biopsy: Severe acute and chronic inflammation invading the submucosa loaded with H. pylori; no evidence of carcinoma. Medication Amoxicillin 1000 mg, twice daily, orally for 14 days. If you experience any stomach discomfort, you may take with food. Clarithromycin 500 mg, twice daily, orally for 14 days. If you experience any stomach discomfort, you may take with food. Esomeprazole 40 mg once daily for 4 weeks. Take on an empty stomach at least 60 minutes prior to eating. Will likely continue this medication for 6 months. Multivitamin with Iron, once daily, orally. Take this medication at least 2 hours before or 2 hours after taking your other medication. Consults/Referrals Due to your age, complexity, and presence of ongoing symptoms, a referral to gastroenterology has been placed, STAT. They will contact you to schedule an appointment. Client Education Take your antibiotics exactly as prescribed. The full 14-day course needs to be completed despite any improvement in symptoms. Eat smaller meals and do not eat within two hours of going to sleep. Your diet should be enriched with high-fiber foods. Avoid processed, fried, fatty and spicy foods. Do not smoke, smoking increases your risk of delayed healing and complications. If interested, we could try a nicotine patch to help with your cigarette craving or another program to help you quit. It is best if you avoid alcohol consumption, but if you must drink, drink small amounts, try to cut back. Avoid ibuprofen, you can take Acetaminophen as needed for knee pain, if the Acetaminophen is not helping decrease your kneed pain please contact the office. You may continue the use antacids such as Tums as needed however, they should be taken either 2 hours before or 2 hours after taking any of your other medications. Follow-Up Follow up