Case Study 2

Use APA 7th Edition Format and support your work with at least 3 peer-reviewed
references within 5 years of publication. Remember that you need a cover page and a
reference page. All paragraphs need to be cited properly. Please use headers. All
responses must be in a narrative format and each paragraph must have at least 4
sentences. Lastly, you must have at least 2 pages of content, no greater than 4 pages,
excluding cover page and reference page.
Patient With Sudden Onset of Intermittent Mid-Epigastric Pain
PR is a 35-year-old female who presents with a sudden onset of intermittent mid-epigastric pain that
started 4 weeks ago. Pain is 6/10 on the pain scale and described as burning that worsens after she
eats Mexican food and when she is lying down. She has never experienced this before. PR reports
that she has been taking over the counter (OTC) antacids that seemed to help at first, but now they
provide no relief. She reports associated regurgitation and feeling of fullness all the time and this
morning she had a sore throat.
Past Medical History
• Anaphylactic reaction to penicillin Medications
• OTC antacids
Family History
• Noncontributory
Social History
• Occupation: Elementary school teacher (10 years)
• Nonsmoker
• Denies illicit drug use
• Consumes wine two to three times per month •
Regular exercise
Physical Examination
• Weight: 145 lbs.; blood pressure: 128/72; pulse: 80; respiration rate: 18; temperature: 98.7 °F
• General: Calm, cooperative, in no apparent distress
• Eyes: Pupils equal, round, reactive to light
• Ears: Tympanic membranes clear
• Nares: Without nasal septal deviation; pharyngeal mucosa pink and moist
• Throat: Oropharynx without edema, erythema, tonsillar enlargement, lesions
• Abdomen: Nondistended, soft, round, nontender; normoactive bowel sounds in all quadrants
Discussion Questions
1. What are the top three differential diagnoses for PR?
2. What diagnostic tests, if any, are required for PR?
3. What pharmacological, nonpharmacological, and/or nutraceutical therapies should be prescribed
for PR?
4. The results from PR’s H. pylori test returned positive. What treatment should be added to her
plan of care?