Mr. M.J. is a 64-year-old patient of Hispanic descent who presents to the clinic today with concerns about epigastric and substernal pain that has gotten progressively worse over the past 3 months. He complains of mild “heartburn after eating a large meal for at least 2 years. He has tried over the counter products occasionally with adequate response. Three months ago, he was awakened with severe burning discomfort that extended from his mid-chest to his jaw that lasted 30 minutes before he was able to fall back to sleep. He is now experiencing these attacks about 3 times per week. He has tried avoiding large meals and is now sleeping on two pillows at night to relieve his pain which has improved his pain. The pain now occurs regularly after meals and randomly during the day. He takes antacids with each meal, but the pain still persists. Overall, he considers himself to be very healthy.
Past Medical History
Depression diagnosed 6 months ago
Unknown; was adopted from an orphanage when he was 3 months old; Wife died of breast cancer approximately 8 months ago. They were unable to have children.
Drinks beer occasionally when out with friends
No smoking history
Vital Signs: blood pressure 138/72, heart rate 80, respirations 18, temperature 98.6
General: No acute distress. Cooperative
Heart: S1 and S2 regular rate and rhythm without murmurs, rubs or gallops
Lungs: clear to auscultation
Abdomen: Normal contour; positive bowel sounds all 4 quadrants; no bruits; soft to palpation
With no palpable masses. Tenderness noted moderate palpation in the midline upper
Abdomen. No hepatomegaly. No evidence of hernia. Rectal exam reveals soft brown stool
That is negative for occult blood.
Discussion Questions- Please answer the following question in APA format with in text citations. Please put answers in SOAP note format.
What is your primary diagnosis? What evidence based resource and patient data supports this diagnosis?
What two differential diagnoses are appropriate in this patient’s case? What evidence-based resource and patient data supports these two differential diagnoses?
For the primary diagnosis explain how you would proceed with your work-up and include the following: lab work and imaging studies
How would you manage this patient pharmacologically?
What non-pharmacological strategies would be appropriate?
Describe patient education strategies.
Describe follow-up and any referrals that may be necessary.
Based on patient data, you may be concerned that he is exhibiting signs of depression. Whether you address this issue at this office visit or bring him back for another visit, you may be considering placing him on medication. What medication might you prescribe? Support with current evidence.