Question

Practice Differential Diagnosis Assignment

Mr. Eric Parker is a 35 year old African American male, is a regular patient of an urban primary care clinic. His last check up [2 years ago], was normal, including cholesterol of 170 mg/dL. He is married with three school age children and is employed as a division sales representative for a national computer network. In addition, he is an avid runner and fisher man.

CC:     “My stomach has been aching and burning, off and on for the past 2 months”

HPI:     Eric points to his epigastric area and says that the acing and burning occur after meals about three or four times/week and on weekends when he has a few drinks with his family/friends. He expresses concern that the pain might be due to an ulcer, and he would like some medicine prescribed for the discomfort. Eric also experiences sour belches and has noticed this more often and after going to bed at night. His symptoms are usually relieved with antacids. He does not recall any particular food that precipitates the discomfort. He denies nausea, vomiting, diarrhea, constipation, melena or weight loss or gain. He has noticed that his symptoms occur more frequently when the demands @ work are heavy and he is feeling stressed. He denies tobacco or illicit drug use and states that he is conscientious about maintaining a professional image. He denies taking any medications other than Advil one to two times a month for muscle aches after a strenuous workout. There is no family history of alcoholism or other substance abuse.

PMH:   noncontributory

PE:       VS:       98-88-16-136/84                    5’10”               190#

            General:        Middle aged man slightly overweight in NAD

            Skin:                warm, intact without any lesions or rashes

            Abdomen:     flabby; active bowel sounds; no bruits; nontender

                                    without any palpable masses; no organomegaly

            Rectal:            prostate smooth, rubbery; hemoccult negative stool

Laboratory:                normal CBC; AST 21 u/L [10-40]; ALT 28u/L [10-55]; Alk phos 83 u/L [45-115]; GGT 45 u/L [5-38]

What are his medical diagnoses?

What are his differential diagnoses, with rule outs?

What diagnostics are needed?

What prescriptions does he need?

What education does he need?

Answer 1

#. His medical diagnosis is stress ulcer

#. Differential diagnosis are acid reflux , gastritis , gastrointestinal disease , stomach ulcer

#. Diagnostic method Based on symptoms, confirmed by endoscopy or barium swallow.

#. Prescription he need are :-

Antacids

Proton pump inhibitor

Diet modification

Increased fluid intake