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
Family History
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.
Social History
Drinks beer occasionally when out with friends
No smoking history
Current Medications
Multivitamin daily
Physical Exam
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.
GU: unremarkable
Musculoskeletal: unremarkable
Neurological: unremarkable
Skin: unremarkable
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.

Attachments:

• 1506491195-NR 601 DISCUSSION WK 3.docx