NR 576 Week 5 iHuman Virtual Patient Encounter Attempt 3229731 - Willaim Garrett

History Notecard by Marla Patterson on case William Garrett 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 = SxSxSxSxSx = = = = = Onset a few months ago Location its in my upper gut, just below my breast bone Duration its kind of there all the time time, sometimes its worse tha others but its bee there for several monnths Characteristics varies from burning to aching Aggravating skipping a meal makes it worse, an hours after a meal makes it worse Relieving eating makes it better Timing anntacids / Treatments Severity 2 at best, but it can be as high as 6 Attempt: 3229731 Report generated on 8/12/2024, 12:04:38 AM America/New_York Management Plan by Marla Patterson on case William Garrett Medications: 1. Omeprazole 20 mg PO QD 30 minutes before breakfast x 8 weeks #56 with no refills.(Peptic Ulcer disease, 2024). 2. Clarithromycin 500 mg PO BID for 14 days with no refills #14 (Lamont,n.d.). 3. Metronidazole 500 mg PO BID for 14 days with no refills #14 (Lamont, n.d.). Referral: Gastrointestinal referral for diagnostic and treatment of peptic ulcer disease and h. pylori and referral to a dietician for help in his dietary changes that need to be made. (Kavitt, 2019) Education: 1. Take the medication even if symptoms improve 2. Smoking cessation 3. Avoid spicy, greasy, foods with seeds, nuts, hulls, that can irritate the stomach 4. Avoid alcohol, chocolate, caffeine 5. Return to office if you have severe, persistent abdominal pain, vomiting blood, bloody stools, black tarry stools, unexplained weight loos, persistent nausea/vomiting (Gupta et al, 2023). Follow up Schedule a follow up appointment for 4 weeks to assess the response to the treatment or come back sooner if symptoms are not improving or becoming worse. Return sooner if severe persistent abdominal pain or weight loss, vomiting blood, bloody stools, or black tarry stools. Persistent nausea or vomiting (Gupta et al. 2023) References: Gupta, A., Shetty, S., Mutalik, S., Chandrashekar H, R., K, N., Mathew, E. M., Jha, A., Mishra, B., Rajpurohit, S., Ravi, G., Saha,M., & Moorkoth, S. (2023, September 24). Treatment of H. pylori infection and gastric ulcer: Need for novel pharmaceutical formulation. Heliyon. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10550623/ Kavitt, R. T., Lipowska, A. M., Anyane-Yeboa, A., & Gralnek, I. M. (2019). Diagnosis and treatment of peptic ulcer disease. The American Journal of Medicine, 132(4), 447–456. https://doi.org/10.1016/j.amjmed.2018.12.009 Lamonnt, T. (n.d.). Treatment regimens for Helicobacter pylori in adults. UpToDate. https:// www.uptodate.com/contents/treatment-regimens-for-helicobacter-pylori-in-adults Electronic Health Record by Marla Patterson on