Aquifer Case Study – Peptic Ulcer Disease

Aquifer Case Study – Peptic Ulcer Disease

The case revolves around Mr. Rodriguez, a 39-year-old Latino immigrant from the Dominican Republic who has been in the United States for the last 12 years. The primary concern of the client at the first visit to the clinic was the sudden aggravation of slow and dull pain in his abdomen, and he wanted to trace the underlying issue. He had a persistent discomfort in the stomach with burning sensations in the upper stomach region during the preceding 12 months of his visit. A patient reports that eating or drinking sometimes relieves or worsens the pain but invariably eats spicy dishes. Mr. Rodriguez comes from a farmworker background and just quit smoking also, but for beer, he is moderate, just three to four per week at the very most. On the family tree of his parents, he had hypertension before. The patient denies medical events of the past and, more often, self-medicates with a couple of tablets of aspirin and herbal tea for stomach discomfort.

Diagnosis

Pylori Gastritis | ICD-10 CODE B96.81

Rationale: H. pylori gastritis results from an H. pylori infection of the glandular stomach. It is a stomach infection that brings about stomach inflammation and, if not treated, may cause peptic ulcers (Fahim et al., 2022). Gastric irritation related to H. pylori can exhibit chronic upper abdominal discomfort (depression, gnawing, or severe) pain. The feeling may be mild or broad – ranging from distracting to incapacitating pain, coming and going, or happening throughout the day. The cause is overindulging in spicy or acidic foods, but antacids or medications that reduce acid production can temporarily ease the discomfort. Ms. Rodriguez’s symptoms, including stabbing pain in the stomach area brought on by spicy foods, and his risk factors, such as his previous smoking and alcohol consumption, closely match H. pylori gastritis diagnosis.

Differential Diagnosis #1

Peptic Ulcer Disease | ICD-10 CODE K27.9

Rationale: Peptic ulcer disease is the term for ulceration that occurs from the opening sores in the stomach or upper small intestine, resulting from the immune system imbalance of the stomach’s acid-protective lining. Hence, patients may experience mid-chest fullness, heartburn, or continuous hunger, which often improves with eating. While Mr. Rodriguez’s pain is similar to gastritis, eating or drinking does not consistently alleviate his symptoms, which is a characteristic of PUD (Kavitt et al., 2019). However, the presence of H. pylori infection increases the risk of developing peptic ulcers, making PUD a potential complication or differential diagnosis.

Differential Diagnosis #2

Gastroesophageal Reflux Disease | ICD-10 CODE K21.9

Rationale: Gastroesophageal reflux disease (GERD) represents a chronic condition characterized by esophagus regurgitation of stomach acid and possibly other gastrointestinal contents, respectively, brought about by symptoms and potential intraesophageal mucosal tissue injury. Pain in the upper abdomen may be caused by either gastritis or GERD, although the specifics of where and how the pain manifests might differ (Antunes et al., 2021). The discomfort associated with gastritis is usually felt in the upper abdomen, whereas the pain associated with gastroesophageal reflux disease (GERD) is more often reported in the chest; however, Mr. Rodriguez does not report this.

Treatment, Education, and Follow-Up

Based on the clinical practice guidelines for the management of H. pylori infection, the recommended treatment plan includes

1. Antibiotic therapy: A combination of two or more antibiotics, such as amoxicillin, clarithromycin, metronidazole, or tetracycline, for 7-14 days. The most commonly recommended regimen is a triple therapy consisting of a proton pump inhibitor (PPI), clarithromycin, and amoxicillin or metronidazole (Malfertheiner et al., 2017).
2. Proton pump inhibitors (PPIs): Proton pump inhibitors (PPIs): Short-term treatment should be implemented by use of high-dose PPIs, e.g., omeprazole or esomeprazole, concurrent with antibiotics and at least two weeks after the course of unfinished antibacterials.

Patient Education

Patient education is crucial and should cover the following aspects:

1. Medication adherence: Emphasize the significance of finishing the antibiotics and PPIs the entire course to ensure the bacteria of H. pylori and ulcer healing are successfully eradicated.
2. Dietary modifications: Suggest keeping away from foods that will irritate the ulcer, such as spiced, citrusy, or caffeinated dishes and drinks, until the ulcer has healed completely.
3. Lifestyle changes: Recommend smoking cessation and limiting quantities of alcohol consumption in these contend as they can prevent ulcer recovery and increase their chances of reoccurrence.

Follow-Up

Follow-up care should involve:

1. Repeat endoscopy: Following 4-8 weeks beyond the treatment course, the endoscopy to be repeated assesses ulcer healing and confirms H.pyori eradication (Malfertheiner et al., 2017). The endoscopy technique is the only one that does not allow the observation of the ulcer’s healing progress and the detection of any complications or recurrence.
2. Monitoring for recurrence: Regular revisiting by the physician would be necessary to check on symptoms to determine the need for other forms of medication and to solve potential side effects. Continuous monitoring may be needed in patients who are known to have complicated or resistant ulcers. The main objective is to detect and manage early signs of relapse immediately to avoid further complications.

References

2023 ICD-10-CM Diagnosis Code K21.9: Gastro-esophageal reflux disease without esophagitis. (n.d.). ICD.Codes. Retrieved April 27, 2024, from https://icd.codes/icd10cm/K219

2023 ICD-10-CM Diagnosis Code K27.9: Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation. (n.d.). ICD.Codes. Retrieved April 27, 2024, from https://icd.codes/icd10cm/K279

2023 ICD-10-CM Diagnosis Code K29.70: Gastritis, unspecified, without bleeding. (n.d.). ICD.Codes. Retrieved April 27, 2024, from https://icd.codes/icd10cm/K2970

Antunes, C., Aleem, A., & Curtis, S. A. (2021). Gastroesophageal Reflux Disease. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/28722967/

Fahim, S. M., Das, S., Gazi, Md. A., Alam, Md. A., Hasan, Md. M., Hossain, Md. S., Mahfuz, M., Rahman, M. M., Haque, R., Sarker, S. A., Mazumder, R. N., & Ahmed, T. (2020). Helicobacter pylori infection is associated with fecal biomarkers of environmental enteric dysfunction but not with the nutritional status of children living in Bangladesh. PLoS Neglected Tropical Diseases, 14(4), e0008243. https://doi.org/10.1371/journal.pntd.0008243

Kavitt, R. T., Lipowska, A. M., Anyane-Yeboa, A., & Gralnek, I. M. (2019). Diagnosis and treatment of peptic ulcer disease. The American Journal of Medicine, 132(4), 447-456. https://doi.org/10.1016/j.amjmed.2018.12.009

Malfertheiner, P., Megraud, F., O’Morain, C. A., Gisbert, J. P., Kuipers, E. J., Axon, A. T., … & Gasbarrini, G. (2017). Management of Helicobacter pylori infection—the Maastricht V/Florence consensus report. Gut, 66(1), 6-30. https://doi.org/10.1136/gutjnl-2016-312288

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Hello, so this Aquifer Case Study (The story of the case study is in the sample Aquifer F19, and the summary is attached. Please make sure to follow the rubrics…It has to be exactly 3 pages only. Just follow the outline that I give. You can just use the sample Aquifer and just change the wording and references. The references must be a clinical guideline and peer-reviewed. See bthe below outline. Please please just follow the outline. Thanks so much. The main diagnosis must be Peptic Ulcer Disease and for differential diagnosis, you can put GERD, GASTRITIS or Pancreatitis explain the rationale why it is not the main diagnosis. and also give a rationale for why PEPTIC ULCER is the main diagnosis. Please put ICD-10. Please make sure it’s plagiarism-free as we are using TURN IT IN SCORE thanks

Aquifer Case Study – Peptic Ulcer Disease

Aquifer Essay Title
The introduction should be a paragraph that provides a brief overview of the case and main diagnosis with rationale and supporting evidence. You do not need to discuss pathophysiology or summarize the entire case. The entire paper should be between one and three pages long.
Differential Diagnoses
This section will idat the main diagnosis.
Diagnostics
Identify the lab, radiology, or other tests needed for the main diagnosis with supporting evidence. Do not include excessive or non-pertinent testing.
Treatment, Education, and Follow-Up
This section should include the elements of an initial treatment plan for the main diagnosis. It should include medication names, dosages, frequencies; patient/family education; appropriate follow-up plan; and hospitalizations and consults when appropriate.