In this week’s clinical rotation, I further learned how to better assess and examine patients in the primary care setting. In the hospital setting, I am used to performing full body exams on all of my patients each shift. In the primary setting, assessments seem to be a little less complex in some ways however more challenging in other ways. For example, the provider in the primary care clinic are not challenged with assessing intravenous lines, pressure injuries, or cardiac rhythms on every single patient. While these assessments may present themselves occasionally in the primary setting, they are extremely common in the hospital setting. While this may allow assessments to be more streamlined in some aspects, challenges also exist in the primary setting due to these differences. For example, if a provider senses a cardiac abnormality, the patient may be required to undergo certain tests and exams that may not be available in the primary care clinic. In this case, I have seen many examples of “tentative” diagnoses that my preceptor makes until the patient is able to undergo further testing.I am still trying to get used to the differences in resources within the hospital and primary care setting.
This week, a 27 year old female patient presented to the clinic with complaints for heartburn that has lasted for the last three months. She presented with a temperature of 98.6 F, heart rate of 76, blood pressure of 132/76, 16 respirations per minute, and spO2 of 99% on room air. Additionally, she stood at 5 feet 6 inches and weighed 170 pounds, putting her body mass index at 27.4. Her current pain was rated a 3/10 and reported it to be dull and within her epigastric region. She described her typical heartburn sensation as a dull burning sensation that has occurred approximately 30 minutes after eating any meal for the last three months. She stated that she tries to eat bland and avoids spicy food. She also reported to have tried over-the-counter omeprazole for a month with no relief. My preceptor diagnosed her with gastroesophageal reflux disease, otherwise known as GERD, and prescribed her 40 mg pantoprazole twice a day as well as a stool sample to examine for presence of blood. Differential diagnosis includes peptic ulcer disease, gastritis, gastroparesis, angina, hiatal hernia, H. pylori infection, and irritable bowel syndrome (Cesario et al., 2018). Diagnostic testing includes endoscopy and biopsy, 24-hour ambulatory reflux monitoring, esophageal manometry, and a barium x-ray of the upper digestive system (Gyawali et al., 2018). Furthermore, patients can be started on a proton pump inhibitor trial, as in the case of this female patient, which will allow the patient and provider to determine relief from symptoms with medication use (Gyawali et al., 2018). However, this technique runs the risk of over-diagnosing GERD and overusing proton pump inhibitors (Gyawali et al., 2018).This patient was instructed on following medication plan as ordered and to follow up with the clinic in one month to determine effectiveness.
This week’s clinical experience allowed me to further improve on my assessment skills and collaborate with my preceptor. Additionally, I am feeling more comfortable with educating patients on lifestyle modifications they can make to improve their symptoms and overall quality of life. I educated this patient on avoiding foods that trigger reflux such as fatty foods, fried foods, spicy foods, citrus, alcohol, and caffeine (Mayo Clinic, 2020). I also advised the patient avoid laying down after meals and to use an additional pillow to elevate her head while in bed. Additionally, I encouraged the patient to initiate some regular exercise into her daily routine and maintain a healthy weight, as her BMI sets her at a higher risk of GERD and complications.She agreed with the treatment plan and verbalized understanding of the improvements she could implement.
References
Cesario, S., Scida, S., Miraglia, C., Barchi, A., Nouvenne, A., Leandro, G., Meschi, T., De’ Angelis, G. L., & Di Mario, F. (2018). Diagnosis of GERD in typical and atypical manifestations. Acta bio-medica : Atenei Parmensis, 89(8-S), 33–39. https://doi.org/10.23750/abm.v89i8-S.7963
Gyawali, C. P., Kahrilas, P. J., Savarino, E., Zerbib, F., Mion, F., Smout, A. J., … & Roman, S. (2018). Modern diagnosis of GERD: the Lyon Consensus. Gut, 67(7), 1351-1362.
Mayo Clinic. (2020, May 22). Gastroesophageal reflux disease (GERD). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/gerd/diagnosis-treatment/drc-20361959.
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