39-year-old male with epigastric pain

39-year-old male with epigastric pain

This paper is on a Family Medicine 19: 39-year-old male with epigastric pain. You are to Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case

Family Medicine 19: 39-year-old male with epigastric pain

Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case: Family Medicine 19: 39-year-old male with epigastric pain.

Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and also your understanding of why they were important to collect for this case history. Use specific references from your text to explain.

Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.

Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.

Discussion Question 4
Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.

Discussion Question 5

Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.

Today, you are working at a family medicine clinic with Dr. Medel. Together, you review her clinic schedule for the day and also she suggests that you see Mr. Cesar Rodriguez, a 39-year-old uninsured male who recently moved to the U.S. from the Dominican Republic. This is Mr. Rodriguez’s first visit to the clinic.

Molly, Dr. Medel’s medical assistant, has already escorted Mr. Rodriguez to the examination room and has arranged for a Spanish-speaking interpreter to be present for the visit, since he speaks and also comprehends very little English. Molly tells you that Mr. Rodriguez has been having “worsening abdominal pain over the past several months” and is “worried that something is wrong.”

Dr. Medel says to you, “How would you begin to think about what might be going on with Mr. Rodriguez?”

You reply, “Abdominal pain can be caused by a wide variety of conditions. I’ll need to get more information about his symptoms to form an appropriate differential diagnosis. At this point I’d have to consider several organ systems as potential etiologies of the pain.”

“Very good,” Dr. Medel responds. “Why don’t you go ahead and talk with Mr. Rodriguez and also come find me afterward. Lola, our Spanish-speaking interpreter, can help.”

As you walk down the hall, Lola, the Spanish-speaking interpreter, also,  gives you some tips on how to interview a patient with an interpreter.

You and Lola enter the room. You sit directly across from Mr. Rodriguez, with Lola sitting just off to your left and facing him. You sense that Mr. Rodriguez seems anxious about coming to the physician today. You introduce yourself and ask,
“What brings you in today?”

“Is there anything that makes the pain better or worse?”

“What worries you the most about your symptoms?”

Thinking about some of the common causes of abdominal pain, you conduct a focused review of systems:

General: Reports no weight loss, fevers, chills, or night sweats. He has had no recent illnesses. Aside from a recent move to the U.S. from the Dominican Republic, he has not traveled recently.

GI: Reports no dysphagia, regurgitation, nausea, vomiting, anorexia, early satiety, hematemesis, hematochezia, melena, diarrhea, or constipation.

GU: Reports no dysuria, hematuria, or change in frequency.

CVS/Respiratory: Reports no chest pain, cough, or shortness of breath.

MEDICAL AND FAMILY HISTORY
HISTORY
You now direct your attention to Mr. Rodriguez’ medical history.

“Do you have any chronic medical problems?”

“Have you ever been hospitalized or had any surgeries?”

“Do you take any medicines or supplements?”

“Does anyone in your family have any medical conditions—for example, heart or blood pressure problems? Diabetes?”
“Does anyone in your family have stomach problems or pain similar to yours?”

You ask Mr. Rodriguez a few more questions and discover that he works as a farm laborer. He has no known drug allergies. He smoked a few cigarettes daily but quit six months ago. Further, he drinks three to four beers per week. Also, he reports no other drug use. He has had no recent illnesses. Aside from a recent move to the U.S. from the Dominican Republic, he has not traveled recently.

You congratulate Mr. Rodriguez on quitting smoking and you thank him for answering all of your questions. Further, you review in your mind what you’ve learned from Mr. Rodriguez so far, and find yourself still wondering about why he seems a little anxious. Before you go to get Dr. Medel, you inquire, “It seems like this has really been bothering you. Is there anything else we haven’t talked about that seems important?”

CONTINUE