NR 511 Week 5 iHuman Virtual Patient Encounter Attempt 2632375 - Luca Alaniz

History Notecard by Amy Nelson on case Luca Alaniz 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: 2632375 Report generated on 2/12/2023, 11:52:05 AM America/Denver Management Plan by Amy Nelson on case Luca Alaniz Diagnosis: H. Pylori (PUD) Pharmacological regime: PPI- Omeprazole 20 mg 1 po bid may need for up to 6 weeks. Antibiotic therapy- Clarithromycin 500 mg po bid and Amoxicillin 1 gram po bid x 14 days (Epocrates Web, 2023). Education: Stop smoking (offer nicotine patch), avoid alcohol intake, and any foods that may worsen symptoms. Stop all NSAID use (Hollier, 2021). Referrals/consults: Return to GI for Endoscopy in 6-12 weeks to ensure the ulcer is healing (Hollier, 2021). Follow-up: Return to office in 14 days for a retest of H. Pylori stool antigen test. Present to the ER for chest pain, low blood pressure, rectal bleeding, and increased heart rate (Hollier, 2021). Diagnosis: Anemia/GI Bleed Pharmacology: Multivitamin with iron daily x 1 month, then repeat CBC (Hollier, 2021). Education: Eat a diet high in protein and iron, such as meat, beans, and green leafy vegetables. Follow-up: Schedule a colonoscopy due to dark tarry stools, which the PUD can cause; however, further diagnosis is necessary (Hollier, 2021). References: (2023). Epocrates Web. https://online.epocrates.com/ Hollier, A. (2021). Clinical guidelines in primary care. Attempt: 2632375 Report generated on 2/12/2023, 11:52:05 AM America/Denver Social History Category Data entered by Amy Nelson Social History Married and lives with his wife. Recently retired. tobacco use of 1 ppd for the last 35 years. ETOH 2-3 glasses of wine or mixed drinks 2-3 times a week. Denies illicit drug use Review of Systems Category Data entered by Amy Nelson General Awake and alert, no acute distress, and feeling fatigued due to limited sleep. Integumentary / Breast HEENT / Neck No C/O Cardiovascular No C/O Respiratory Denies sob, wheezing, difficulty catching his breath, chronic cough, or sputum production Gastrointestinal Abdominal pain was intermittent and mild but worse now. pt states had some dark tarry stools. Denies nausea, vomiting, or diarrhea Genitourinary Musculoskeletal C/o bil knee pain Allergic / Immunologic Endocrine Denies heat or cold intolerance, increased thirst, increased sweating, frequent urination. + weight loss and decreased appetite Hematologic / Lymphatic Neurologic Denies any problems with dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, or tremors. Psychiatric