Discuss the Mr. Rodriquez’s history that would be pertinent

Posted: February 15th, 2023

Apply information from the Aquifer Case Study to answer the following discussion questions:

Discuss the Mr. Rodriquez’s history that would be pertinent to his gastrointestinal problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
Describe the physical exam and diagnostic tools to be used for Mr. Rodriguez. Are there any additional you would have liked to be included that were not?
Please list 3 differential diagnoses for Mr. Rodriguez and explain why you chose them. What was your final diagnosis and how did you make the determination?
What plan of care will Mr. Rodriquez be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
Do 2 pages

Provide references.
Mr. Rodriguez’s Pertinent History
Chief Complaint: Mr. Rodriguez presents with abdominal pain and persistent diarrhea.
History of Present Illness (HPI): The symptoms have been ongoing for two weeks, with increasing severity. The pain is described as crampy and diffuse, with no specific aggravating or relieving factors identified. The diarrhea is watery, without blood or mucus.
Social History: Mr. Rodriguez works in a stressful job environment, does not use tobacco, and drinks alcohol socially. He has recently traveled abroad.
Family History: There is a history of colorectal cancer in his family, with his father being diagnosed at the age of 60.
Past Medical History: Notable for type 2 diabetes mellitus managed with oral hypoglycemics.
Physical Exam and Diagnostic Tools
Physical Examination: Vital signs are within normal limits. Abdominal examination reveals diffuse tenderness without guarding or rebound. No masses are palpable, and bowel sounds are normal.
Diagnostic Tools:
Complete Blood Count (CBC): To check for signs of infection or anemia.
Stool Analysis: To identify any infectious agents or blood.
Abdominal Ultrasound: To visualize the liver, gallbladder, and other abdominal organs for any abnormalities.
Additional Tools Desired:
Colonoscopy: Given the family history of colorectal cancer and persistent symptoms, a colonoscopy would be valuable for direct visualization of the colon and possible biopsy.
Differential Diagnoses
Infectious Gastroenteritis: Given the recent travel history and symptoms of diarrhea.
Irritable Bowel Syndrome (IBS): Considering the stress and the nature of the symptoms.
Inflammatory Bowel Disease (IBD): Given the persistent symptoms and family history of gastrointestinal issues.
Final Diagnosis: The determination would depend on the results of the diagnostic tests, particularly stool analysis and colonoscopy. If infectious agents are identified, an infectious gastroenteritis could be confirmed. If the colonoscopy reveals characteristic changes, IBD could be diagnosed.
Plan of Care
Drug Therapy and Treatments:
For infectious gastroenteritis, appropriate antibiotics based on stool culture results.
For IBS, antispasmodics and dietary modifications.
For IBD, corticosteroids and immunosuppressants may be initiated.
Patient Education:
Dietary advice, including hydration and avoidance of trigger foods.
Importance of medication adherence.
Symptoms monitoring and when to seek further medical attention.
Follow-up: Scheduled in 4-6 weeks to assess response to treatment or sooner if symptoms worsen.
References
Gastrointestinal Emergencies in Neonates: A Review Article
A Review of Slipping Rib Syndrome: Diagnostic and Treatment Updates to a Rare and Challenging Problem
Endoscopic Management of Foreign Bodies in the Gastrointestinal Tract: A Review of the Literature
Laboratory evaluation of gastrointestinal disease
Detection of Parkinson’s Disease Using Clinical Diagnostic Tools
___________________________
Pertinent Patient History

Chief Complaint: Abdominal pain and diarrhea for 3 days.

History of Present Illness (HPI): Mr. Rodriguez, a 42-year-old male, presented with a 3-day history of intermittent, crampy abdominal pain localized to the periumbilical region, along with watery, non-bloody diarrhea occurring 4-5 times per day. He reported no fever, vomiting, or recent travel.

Social History: Relevant details include his occupation as a construction worker, moderate alcohol consumption, and denial of tobacco or illicit drug use.

Family History: No significant family history of gastrointestinal disorders was reported.

Past Medical History: Mr. Rodriguez had no known medical conditions or prior surgeries.

Physical Examination and Diagnostic Approach

Physical Examination: Vital signs were within normal limits. Abdominal examination revealed mild tenderness in the periumbilical region without guarding or rebound tenderness. No masses or organomegaly were appreciated.

Diagnostic Tools: Based on the case study, the following diagnostic tests were ordered:

Complete blood count (CBC)
Basic metabolic panel (BMP)
Stool sample for ova and parasites, Clostridium difficile toxin, and culture
Additional Tests: To further evaluate the cause of Mr. Rodriguez’s symptoms, the following tests could have been considered:

Abdominal imaging (e.g., CT scan or ultrasound) to assess for structural abnormalities or complications.
Endoscopic procedures (e.g., colonoscopy or sigmoidoscopy) to visualize the gastrointestinal tract and obtain tissue samples if necessary.
Serological testing for inflammatory bowel diseases or other autoimmune conditions, if clinically indicated.
Differential Diagnoses

Acute Gastroenteritis: Viral or bacterial infections of the gastrointestinal tract can cause abdominal cramping, diarrhea, and dehydration. This diagnosis is supported by the acute onset of symptoms and the lack of concerning features such as fever or bloody stools.
Inflammatory Bowel Disease (IBD): Conditions like Crohn’s disease or ulcerative colitis can present with episodic abdominal pain and diarrhea. However, the absence of systemic symptoms and a family history of IBD make this diagnosis less likely in Mr. Rodriguez’s case.
Irritable Bowel Syndrome (IBS): IBS is a functional gastrointestinal disorder characterized by chronic or recurrent abdominal pain, bloating, and altered bowel habits. The acute nature of Mr. Rodriguez’s symptoms and the lack of a prior history of IBS make this diagnosis less probable.
Final Diagnosis and Determination

Based on the clinical presentation, laboratory results (if available), and the exclusion of more serious conditions, the most likely diagnosis for Mr. Rodriguez is acute gastroenteritis, likely viral in origin.

Plan of Care

Pharmacological Management:
Oral rehydration solutions (e.g., Pedialyte) to replace fluid and electrolyte losses.
Antidiarrheal medications (e.g., loperamide) may be prescribed if diarrhea is severe or prolonged.
Antiemetics (e.g., ondansetron) if nausea and vomiting are present.
Non-pharmacological Interventions:
Dietary modifications: Recommend a bland, low-fiber diet until symptoms improve, and gradually reintroduce solid foods.
Hydration: Encourage increased fluid intake to prevent dehydration.
Rest and symptom management.
Patient Education:
Explain the self-limiting nature of acute gastroenteritis and the importance of staying hydrated.
Provide instructions on when to seek medical attention (e.g., severe or persistent symptoms, signs of dehydration).
Emphasize good hand hygiene and food safety practices to prevent transmission.
Follow-up:
Advise Mr. Rodriguez to follow up if symptoms persist beyond 5-7 days or worsen.
Schedule a follow-up appointment if necessary, based on the clinical course and response to treatment.
Bibliography

Riddle, M. S., DuPont, H. L., & Connor, B. A. (2016). ACG clinical guideline: diagnosis, treatment, and prevention of acute diarrheal infections in adults. American Journal of Gastroenterology, 111(5), 602-622. https://doi.org/10.1038/ajg.2016.126
Lacy, B. E., Pimentel, M., Brenner, D. M., Chey, W. D., Keefer, L. A., Long, M. D., & Moshiree, B. (2021). ACG clinical guideline: management of irritable bowel syndrome. American Journal of Gastroenterology, 116(1), 17-44. https://doi.org/10.14309/ajg.0000000000001036
Feuerstein, J. D., & Cheifetz, A. S. (2017). Crohn’s disease: epidemiology, diagnosis, and management. Mayo Clinic Proceedings, 92(7), 1088-1103. https://doi.org/10.1016/j.mayocp.2017.04.010
Ungaro, R., Mehandru, S., Allen, P. B., Peyrin-Biroulet, L., & Colombel, J. F. (2017). Ulcerative colitis. The Lancet, 389(10080), 1756-1770. https://doi.org/10.1016/S0140-6736(16)32126-2
Schiller, L. R., & Pardi, D. S. (2022). Acute infectious diarrhea in adults: etiology, clinical manifestations, and diagnosis. UpToDate. Retrieved from https://www.uptodate.com/contents/acute-infectious-diarrhea-in-adults-etiology-clinical-manifestations-and-diagnosis