Family Medicine 19: 39-year-old male with epigastric pain
The ideal summary statement concisely highlights the most pertinent features without omitting
any significant points. The summary statement above includes:
Epidemiology and risk factors: 39-year-old previously well Latino immigrant.
Key clinical findings about the present illness using qualifying adjectives and descriptive
language:
Chronic progressively worsening
No vomiting, hematemesis, hematochezia, melena, or association with meals
Quit smoking
Occasional alcohol consumption
Uses NSAIDs
Uses traditional herbal teas
Week 3 Gastrointestinal Discussion
Discuss 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.
Mr. Rodriguez’s chief complaint is abdominal pain. His history of present illness is abdominal
pain that began a year ago and the abdominal pain occurred a few times a week, but now hurts
every day. The patient reports burning in his epigastric area. His social history includes that he
works as a farm laborer and reports a history of smoking cigarettes, drinking 3-4 beers a week,
and denies drug use. Mr. Rodriguez reports that he quit smoking 6 months ago and says he has
not traveled recently. The patient is a Latina immigrant who takes NSAIDs frequently and
consumes herbal teas occasionally. The patient reports a family history of his father having
hypertension and his mother having diabetes. The patient denies any medical problem except the
existing stomach pain. The patient reports no known allergies.
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?
The physical exam used for Mr. Rodriguez is a head-to-toe assessment. The provider also did a
focused assessment of the abdomen. The diagnostic tool that was used was a basic review of
symptoms and an assessment. The diagnostic test performed to diagnose the patient is an H.
pylori fecal antigen test, H. pylori serology, urease breath test, and a fecal occult blood test. I
believe it would be important for the patient to use a food diary to determine what foods cause
improvement or worsening symptoms to see if modifying the patient’s lifestyle will bring about
positive results. It would also be helpful to refer the patient for an upper endoscopy to rule out
other significant GI diseases.
