Nursing

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently in a similar patient evaluation?

CASE IS ALREADY STARTED JUST NEED THE 3 REMAINING SECTIONS

ANSWER

EPISODIC SOAP NOTE

A.

Differential Diagnoses

Most likely diagnosis #1 – Gastroesophageal reflux disease

Gastroesophageal reflux disease is among the most predominant chronic diseases. Acid regurgitation and heartburn are among the usual symptoms while atypical symptoms are highly diverse including chronic cough, chest pain and throat irritation (Herregods, Bredenoord and Smout, 2015). Gastroesophageal reflux disease occurs as a result of stomach acid frequently flowing back into the tube connecting your stomach and mouth. The acid reflux can irritate the esophagus lining. The acid reflux tends to lead to uncomfortable burning in the chest which can radiate up to the neck. In some case Gastroesophageal reflux disease results to challenges in swallowing and breathing difficulties. Esophageal heartburn and burning are some of the major symptoms of the disease. Other major symptoms include chest pain, swallowing difficulties, regurgitation of sour fluid or food and sensation of lump in the throat.

Peptic Ulcer Disease

Peptic Ulcer Disease consists of painful ulcers and sores that develop in the lining of the stomach or the duodenum (the first part of the small intestines). Considerably, there is a thick layer of mucus that protects the stomach lining from the impacts of digestive juices. Ulcers appear wen the stomach acid begins to destroy the lining of the digestive tract. Some people fail to encounter any symptoms of Peptic Ulcer Disease but signs of the disease can be vomiting, bloating, heartburn and a burning pain that appears at the upper or middle stomach at night and between meals. Upper abdominal pain is one of the major symptoms due to the painful sores that are present in the stomach lining (Vakil, Vieth, Wernersson, Wissmar and Dent, 2017). Other usual symptoms include epigastric pain, dyspepsia and pain that radiates after completion of a meal and anorexia. The predominant age range is 60 years and above which means the patient is in the correct age range. The patient has complained of epigastric pain and that the pain began after a large meal.

Gastric Cancer

Gastric cancer entails a disease that malignant cancer cells develop in the lining of the stomach. Diet, age and stomach disease can influence the risk of having gastric cancer (Pinheiro, Oliveira, Seruca and Carneiro, 2014). The main risk factor of Gastric cancer is Helicobacter pylori. The other risk factors comprise of eating highly preserved and salted foods. The symptoms of gastric cancer include stomach pain or discomfort as well as indigestion, non-specific complaints of abdominal pain, belching, nausea vomiting, anorexia, pain after eating a meal and constipation. The abdominal pains after eating are all consistent. The patient reports mid epigastric pain that occurs with other common symptoms such as belching, constipation and heartburn.

Biliary disease

Biliary disease entails disease that affect the gallbladder, bile ducts and other structures that are involved in the transportation and production of bile. Some of the symptoms of Biliary disease include abdominal pain, loss of appetite, vomiting and nausea, chills and itching. The upper abdominal pain may be severe with frequent heartburn which sometimes spreads to the throat and causes a sour taste in the mouth. Biliary disease can also result from bile reflux which is a condition that occurs when bile and other contents such as pancreatic enzymes and bicarbonates flow upward from the duodenum into esophagus and stomach. Bile reflux may lead to a potentially serious issue that causes inflammation and irritation of the esophageal tissue.

P

Diagnostics

Order the following visits

Endoscopy: A gastroenterologist needs to be consulted since they are highly specialized medical expertise with knowledge of the digestive tract and are qualified to examine and manage the digestive tract disorder or diseases. An endoscopy may be conducted to determine the cause of the unexplained epigastric pain.

1. pylori: The patient requires a helicobacter pylori test that detects any infections in the digestive tract that have been caused by the bacteria thus enabling diagnosis and treatment of the symptoms (Jonaitis, Pellicano and Kupcinskas, 2018).

Labs: Complete blood count is required to rule out anemia as well as other deficiencies.

Abdominal CT Scan: A diagnostic imaging test is required to help in detecting disease in the internal organs and digestive tract.

Rx:

Treatment:

Conditions such as epigastric pain may require long treatment that will manage the symptoms. The patient should be offered with GERD a full dose PPI for one or two months. Since anti acids require a minimum of thirty minutes to take effect, they can be taken before a meal that might cause heartburn. The patient should sit upright one hour after eating and engage in regular physical activities for a minimum of 30 minutes every day at least five days in a week. Symptoms will be managed by eating small meals at a slow relaxed pace and drinking fluids with meals. The patient will also be required to avoid foods that reduce lower esophageal sphincter pressure such as garlic, onions and alcohol.

References

Herregods, T. K., Bredenoord, A. J., & Smout, A. M. (2015). Pathophysiology of gastroesophageal reflux disease: new understanding in a new era. Neurogastroenterology and Motility: The Official Journal of the European Gastrointestinal Motility Society, 27(9), 1202-1213. doi:10.1111/nmo.12611

Jonaitis, L., Pellicano, R., & Kupcinskas, L. (2018). Helicobacter pylori and nonmalignant upper gastrointestinal diseases. Helicobacter, 23, e12522.

Pinheiro, H., Oliveira, C., Seruca, R., & Carneiro, F. (2014). 9: Hereditary diffuse gastric cancer – Pathophysiology and clinical management. Best Practice & Research Clinical Gastroenterology, 28(Gastric physiology and pathogenesis: evolving concepts and their impact on clinical practice), 1055-1068. doi:10.1016/j.bpg.2014.09.007

Vakil, N., Vieth, M., Wernersson, B., Wissmar, J., & Dent, J. (2017). Diagnosis of gastro‐oesophageal reflux disease is enhanced by adding oesophageal histology and excluding epigastric pain. Alimentary pharmacology & therapeutics, 45(10), 1350-1357.