Evidence based practice questions in Nursing
Today, you are working at a family medicine clinic with Dr. Medel. Together, you review her clinic schedule for the day and she suggests that you see Mr. Cesar Rodriguez, a 39-year-old uninsured male who recently moved to the U.S. from the Dominican Republic. This is Mr. Rodriguez’s first visit to the clinic.
Molly, Dr. Medel’s medical assistant, has already escorted Mr. Rodriguez to the examination room and has arranged for a Spanish-speaking interpreter to be present for the visit, since he speaks and comprehends very little English. Molly tells you that Mr. Rodriguez has been having “worsening abdominal pain over the past several months” and is “worried that something is wrong.”
Dr. Medel says to you, “How would you begin to think about what might be going on with Mr. Rodriguez?”
You reply, “Abdominal pain can be caused by a wide variety of conditions. I’ll need to get more information about his symptoms to form an appropriate differential diagnosis. At this point I’d have to consider several organ systems as potential etiologies of the pain.”
“Very good,” Dr. Medel responds. “Why don’t you go ahead and talk with Mr. Rodriguez and come find me afterward. Lola, our Spanish-speaking interpreter, can help.”
As you walk down the hall, Lola, the Spanish-speaking interpreter, gives you some tips on how to interview a patient with an interpreter.
You and Lola enter the room. You sit directly across from Mr. Rodriguez, with Lola sitting just off to your left and facing him. You sense that Mr. Rodriguez seems anxious about coming to the physician today. You introduce yourself and ask,
“What brings you in today?”
“Well, I’ve been having this abdominal pain, and it just seems like it won’t go away. It started probably a year ago. It used to happen a few times a week, now it hurts every day. It usually burns right here.” (He points to the epigastric area of his abdomen.)
“Is there anything that makes the pain better or worse?”
“It’s hard to say. Sometimes eating or drinking makes it better, or sometimes worse. Sometimes eating spicy foods makes it worse.”
“What worries you the most about your symptoms?”
“I don’t know,” he says nervously. “I just want to make sure nothing is wrong.”
Thinking about some of the common causes of abdominal pain, you conduct a focused review of systems:
· General: Reports no weight loss, fevers, chills, or night sweats. He has had no recent illnesses. Aside from a recent move to the U.S. from the Dominican Republic, he has not traveled recently.
· GI: Reports no dysphagia, regurgitation, nausea, vomiting, anorexia, early satiety, hematemesis, hematochezia, melena, diarrhea, or constipation.
· GU: Reports no dysuria, hematuria, or change in frequency.
· CVS/Respiratory: Reports no chest pain, cough, or shortness of breath.
You now direct your attention to Mr. Rodriguez’ medical history.
“Do you have any chronic medical problems?”
“I don’t really have medical problems, just the stomach pain.”
“Have you ever been hospitalized or had any surgeries?”
“I’ve never been hospitalized. Never been operated on.”
“Do you take any medicines or supplements?”
“Just ibuprofen if I’m tired and sore after work, probably most days of the week. I drink some tea that’s good for the stomach—Yerba Buena—but it doesn’t really help.”
“Does anyone in your family have any medical conditions—for example, heart or blood pressure problems? Diabetes?”
“My father had high blood pressure, my mother had diabetes.”
“Does anyone in your family have stomach problems or pain similar to yours?”
“I don’t know if anyone has these stomach problems like me.”
You ask Mr. Rodriguez a few more questions and discover that he works as a farm laborer. He has no known drug allergies. He smoked a few cigarettes daily but quit six months ago. He drinks three to four beers per week. He reports no other drug use. He has had no recent illnesses. Aside from a recent move to the U.S. from the Dominican Republic, he has not traveled recently.
You congratulate Mr. Rodriguez on quitting smoking and you thank him for answering all of your questions. You review in your mind what you’ve learned from Mr. Rodriguez so far, and find yourself still wondering about why he seems a little anxious. Before you go to get Dr. Medel, you inquire,
“It seems like this has really been bothering you. Is there anything else we haven’t talked about that seems important?”
“Well, I guess I would have come sooner, but I don’t have any health insurance and haven’t had the money to come to the doctor. I want to feel better, but I hope it’s not something serious.”
You reply, “Well, I’m glad you came in today, and I’ll be sure and share your concern with Dr. Medel. Thanks for telling me.”
You ask him to change into a gown, taking off his clothes. You reassure him that you will return with Dr. Medel momentarily, and you and Lola leave the exam room while Mr. Rodriguez changes.
In the hallway, you comment to Lola that you are concerned about why Mr. Rodriguez waited to come see a doctor.
You find Dr. Medel in the clinic precepting room, and she asks you, “Well, what have you learned so far?”
You summarize Mr. Rodriguez’s story for Dr. Medel.
Summary of case study so far: Mr. Rodriguez is a previously well 39-year-old Latino immigrant who presents with chronic progressively worsening pain in his upper abdomen. He reports no vomiting, hematemesis, hematochezia, melena, or association with meals. He recently quit smoking and consumes alcohol occasionally and takes NSAIDs and traditional herbal teas.
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 transformative language:
· Chronic progressively worsening
· No vomiting, hematemesis, hematochezia, melena, or association with meals
· Quit smoking
· Occasional alcohol consumption
· Uses NSAIDs
· Uses traditional herbal teas
Dr. Medel praises your summary and then asks you to commit to a provisional differential diagnosis for Mr. Rodriguez’s abdominal pain, based on your findings from his history.
After careful consideration, you tell Dr. Medel that you are concerned that Mr. Rodriguez has either gastritis, gastroesophageal reflux disease (GERD), or peptic ulcer disease (PUD). You and Dr. Medel discuss the various causes of dyspepsia.
You tell Dr. Medel you are confused as to how to differentiate the etiologies of dyspepsia. Dr. Medel replies, “That is understandable, as this is like piecing together a puzzle. There is no one right answer for every patient. Instead, you have to consider the clinical picture as a whole. We’ll need to consider each possible etiology for dyspepsia for Mr. Rodriguez.”
Dyspepsia: Definition, Symptoms, Epidemiology, and Etiology
Dyspepsia is literally “bad digestion.” Patients commonly describe having “indigestion.”
Patients with this condition experience upper abdominal pain or discomfort that is episodic or persistent. It is often associated with belching, bloating, heartburn, early satiety, nausea, and/or vomiting.
About a quarter of adults are affected by dyspepsia, but many people self-diagnose and self-treat. Even though most people don’t seek medical care for it, dyspepsia accounts for approximately 5% of all visits to family physicians and is the most common symptom leading to GI referral in the U.S.
|Condition||% of Dyspepsia Cases|
|Functional or non-ulcer dyspepsia
(specific etiology for dyspepsia can’t be identified)
|Peptic ulcer disease (PUD)||20%|
|Gastritis / duodenitis||10%|
|Medication side effects||Common|
|Gastric, pancreatic, and esophageal cancer||Important though uncommon (< 2%)|
(such as angina and dissecting aortic aneurysm)
|Rare, but should always be included in ddx|
You tell Dr. Medel that you are still unsure how to differentiate between dyspepsia due to gastroesophageal reflux disease (GERD) and dyspepsia due to peptic ulcer disease (PUD).
Peptic Ulcer Disease Versus Gastroesophageal Reflux Disease Symptoms
Some symptoms of PUD directly contrast those of GERD.
|Characterized by episodic or recurrent epigastric “aching,” “gnawing,” or “hunger-like” pain or discomfort||Classic symptoms of retrosternal heartburn and regurgitation|
|Symptoms occur on an empty stomach and are commonly relieved by meals||More likely to occur when gastric volume is increased (after large meals)|
However, this is not always true, and there can be some differences in symptoms based on the location of an ulcer.
For example, gastric ulcer pain may occur 5 to 15 minutes after eating and remain until the stomach empties, which may be up to several hours in duration; the pain may otherwise be absent during times of fasting. Pain from duodenal ulcers is often relieved by eating, drinking milk, or taking antacids but may return anywhere from 90 minutes to four hours after eating a meal. Both gastric and duodenal ulcers may be associated with nausea and vomiting occurring anytime shortly after eating to several hours later.
Given the population prevalence of obesity and hiatal hernia, conditions that predispose a patient to GERD, it is not uncommon for a patient with PUD to also have GERD.
You and Dr. Medel discuss complications of GERD and PUD.
Dr. Medel tells you about alarm symptoms, concluding, “Mr. Rodriguez does not demonstrate any of these right now, but we should remember them, because any of these symptoms would warrant timely referral to a gastroenterologist for endoscopy.”
Now Dr. Medel says, “Let’s think about how the physical exam might help us narrow our differential. What do you think?”
“That’s a trick question!” you exclaim. “In most cases of patients presenting with symptoms related to GERD and PUD, the physical examination will be normal. But we will want to look for signs of complications.”
Dr. Medel replies, “You’re right. We will want to look for signs of complications, as well as signs of other diseases that could be associated with dyspepsia.”
You knock on the door and ask Mr. Rodriguez if he is ready for you, Lola, and Dr. Medel to re-enter the exam room. Mr. Rodriguez says “Yes,” and you proceed with your exam, which reveals:
· Temperature is 36.9 C (98.5 F)
· Pulse is 78 beats/minute, regular
· Respiratory rate is 16 breaths/minute
· Blood pressure is 123/72 mmHg
· Body mass index is 24.8 kg/m2
General: Well-appearing, middle-aged man.
Head, eyes, ears, nose, and throat (HEENT): Sclera anicteric, no conjunctival pallor, oropharynx without lesion or significant dental abnormality.
Neck: Supple, no mass, lymphadenopathy, or thyromegaly.
Cardiovascular: Regular heart rate and rhythm, S1, S2, no murmurs, rubs, or gallops.
Respiratory: Bilaterally clear to auscultation and percussion without wheezes, rales or rhonchi.
Abdominal: Symmetric appearance without scars or ecchymosis. Normoactive bowel sounds heard in four quadrants. Soft, nondistended, with minimal epigastric tenderness on deep palpation without rebound tenderness or guarding, no hepatosplenomegaly, and no herniae or masses.
Skin: Tanned; no jaundice, several tattoos on his upper extremities, no suspicious lesions.
Extremities: Warm and well-perfused, no cyanosis, clubbing or edema.
You inform Mr. Rodriguez that his symptoms and physical examination so far do not seem to indicate a serious medical problem and tell him that you are going to step out to give him a chance to dress. Seeing Mr. Rodriguez relax a bit in his chair, you feel that he seems somewhat reassured.
You and Dr. Medel discuss your findings and consider a diagnosis and treatment plan. She agrees with your assessment that it is challenging to accurately diagnose Mr. Rodriguez with either non-ulcer dyspepsia, GERD or PUD, or gastritis given the history and exam findings alone.
Dr. Medel asks
“Is there anything about Mr. Rodriguez today that seems to be an urgent concern?”
You consider the list of alarm symptoms and signs of complications that would prompt immediate gastroenterology referral. Cautiously, you reply “No, I don’t think so.”
Together, you, Dr. Medel and Lola re-enter Mr. Rodriguez’s room. You tell him, “At this point, it seems most likely that you may either have some acid from your stomach that is irritating your esophagus, the tube that connects your mouth and stomach, or that you might have irritation from acid in your stomach, ibuprofen, or infection in your stomach, which may have caused an ulcer.” Mr. Rodriguez appears startled at the word “ulcer,” and he becomes visibly more worried as you finish your sentence.
You take a moment to ask him,
“It seems like something I’ve said made you nervous. Did it?”
“I heard you saying it could be some acid in my stomach, but then when you said “ulcer,” I remembered a friend who had to have an operation for a stomach ulcer.”
You reply, “I’m sorry, I didn’t mean to upset you. While we want to carefully consider possible causes, we don’t think your symptoms today represent a serious condition.”
You add, “Sometimes people may experience other symptoms that might indicate more serious disease.” You review the alarm symptoms of potential complications warranting referral to a gastroenterologist with him, asking him to let you know right away if he experiences any of these symptoms. You also give him a patient handout in Spanish.
You tell Mr. Rodriguez that a medication called omeprazole may help reduce or take away his pain and heal a possible ulcer. You instruct him to take 20 mg every day for four weeks, on an empty stomach, 30 minutes prior to the first meal of the day. You also suggest that he cut back on alcohol, caffeine, spicy foods, and ibuprofen, substituting acetaminophen instead. Mr. Rodriguez repeats the instructions back to you correctly after you ask him to do so.
Mr. Rodriguez thanks you adding, “I feel a little better about things, but I’m not sure I can pay for the medication. Do you have any samples in your office?”
You tell him, “Unfortunately, we do not have any samples to give you, but I can direct you to Marcia, one of our nurses, who can help get this medication for you through a patient assistance program.”
Mr. Rodriguez thanks you for your help, and you recommend a follow-up visit in one month to check on his progress.
Mr. Rodriguez returns to the clinic four weeks later. You greet him and Lola, who has returned to serve as his interpreter.
“How have you been feeling since the last visit?”
“The medication you gave me didn’t work. I took it every day just like you said, but I still have burning stomach pain right here (points to epigastrium) every day.”
You remember that Mr. Rodriguez’s symptoms were fairly ambiguous and that classic symptoms of GERD are more specific, so you try to clarify,
“Do you have any burning in your chest after meals or feel like your food is coming back up after you eat it?”
“Have your original symptoms changed? Did you develop any alarm signs or symptoms from the list I gave you?”
“No, not really. I haven’t vomited at all, and I haven’t noticed any black or tarry stools.”
On more detailed questioning and review of his vital signs including weight, you do not elicit any worrisome alarm signs or symptoms from Mr. Rodriguez, but you are concerned that overall his condition has not improved. You excuse yourself for a moment while you go find Dr. Medel.
You find Dr. Medel in the hallway and tell her Mr. Rodriguez’s symptoms have not improved. You relate that the lack of improvement and the absence of classic symptoms of GERD are making you think GERD is a less likely diagnosis. His past NSAID use makes you wonder if he more likely has PUD, with or without H. pylori infection, although he could still have functional/non-ulcer dyspepsia (NUD) as well.
Dr. Medel agrees with your assessment and asks, “Given that PUD is our next most likely diagnosis at this point, but we are still considering functional dyspepsia, what do you think we should do next?”
You and Dr. Medel return to see Mr. Rodriguez and find:
Mr. Rodriguez reports he has not taken any NSAIDs or aspirin since the last visit.
· Pulse is 80 beats/minute and regular
· Blood pressure is 126/75 mmHg
Abdominal exam: He has minimal epigastric tenderness without rebound or guarding, which is unchanged compared to his previous exam four weeks ago.
Rectal exam: Reveals a negative FOBT test, without any evidence of gross blood or anatomic abnormality.
You excuse yourselves from Mr. Rodriguez’s room, reassuring him that you will return shortly.
You tell Dr. Medel, “It’s possible that Mr. Rodriguez may have a peptic ulcer, but I don’t feel that he needs to be emergently evaluated. He hasn’t taken any NSAIDs in over a month, and he doesn’t have a history of excessive use. I am concerned that he could have an ulcer or gastritis due to H. pylori infection. His history of immigrating from the Dominican Republic places him at a higher risk of having this condition.”
Together, you and Dr. Medel decide that you suspect that Mr. Rodriguez may have gastritis or peptic ulcer due to H. pylori. Dr. Medel asks what test should be ordered.
You review the available choices: non-endoscopic-based testing (serology—qualitative or quantitative IgG, stool antigen, urea breath test) and endoscopic-based testing (rapid urease test, gastric biopsy, and tissue culture). You suggest ordering a urea breath test or stool antigen, which are the most sensitive and specific noninvasive tests available, as recommended by the American College of Gastroenterology for the general U.S. population.
Dr. Medel agrees that these are excellent choices, but she reminds you that the patient will have to discontinue his PPI for one to two weeks before he can have these tests done due to their suppressive effects on H. pylori. She also explains that there is a much higher prevalence of H. pylori infection in the immigrant population served by the clinic, which increases the positive predictive value of serologic testing, and that the specificity of the commercial ELISA test being used at the clinic approaches 100%. Though she agrees that serology does not discern active infection from prior exposure, it is less expensive, more convenient for the patient, and has been shown to be an effective test in the primary care workup of younger patients who have no indications for endoscopy. Therefore, she recommends starting with a serologic test for H. pylori with Mr. Rodriguez.
You discuss this infection with Mr. Rodriguez, highlighting that he could have contracted H. pylori as a child and remained asymptomatic for years, that it is common in developing countries like the Dominican Republic, and that it is a treatable condition. You ask him if he has ever heard of H. pylori, and whether or not he has ever been treated for it. He replies that he hasn’t. You tell him that you plan to order a blood test to evaluate his exposure to H. pylori.
You order an H. pylori IgG serology and let him know you’ll call him when the results are ready.
The next day, you and Dr. Medel are reviewing laboratory results. You notice that Mr. Rodriguez’s H. pylori IgG assay is positive:
HELICOBACTER PYLORI IgG ANTIBODY BY EIA—QUALITATIVE
NEGATIVE….. No H. pylori IgG antibody detected
POSITIVE….. H. pylori IgG antibody detected
You have the nurse call Mr. Rodriguez to ask him to come in and discuss the results.
You and Dr. Medel confirm that the patient has no known drug allergies and decide to treat Mr. Rodriguez with standard PPI triple therapy, which the clinic is able to obtain for him through a voucher program.
You give him written instructions in Spanish highlighting how to take the medications and again review alarm signs and symptoms of complicated upper GI disease with Lola’s help. You explain that if he experiences any of these symptoms, he should notify the practice immediately, otherwise he should return in four weeks to re-evaluate his condition.
You also educate him regarding possible temporary side effects of the medications, such as nausea, abdominal pain, diarrhea, and altered taste.
Finally, you explain the possibility of an allergic reaction, as with any medication, and instruct him to call if he experiences any problems such as rash or swelling.
Mr. Rodriguez returns four weeks later. He states that his symptoms of dyspepsia initially improved somewhat after finishing the medication but have since recurred, occurring almost daily. He confirms he took all of the medication exactly as directed without any side effects other than mild diarrhea, which has resolved. Again, he reports no alarm symptoms of complicated upper GI disease.
You obtain an H. pylori fecal antigen test on Mr. Rodriguez, which is positive. Through Lola, you explain to Mr. Rodriguez that the original medication regimen you gave him probably did not cure his H. pylori infection, and that this happens 20% to 30% of the time.
Mr. Rodriguez asks, “Can it be cured? My family is here with me from the Dominican Republic. Should they be tested too?”
Dr. Medel replies, “We will give you an additional medication regimen that will hopefully work. Your family members do not need to be tested or treated unless they have symptoms like yours.”
He says, “I’m worried that I will always have these symptoms. Sometimes my pain is very bad, but sometimes it gets better if I drink some milk or eat a meal.” Again, he reports no alarm symptoms of complicated upper GI disease but does continue to report episodic epigastric pain.
You prescribe levofloxacin triple therapy and work with Monica to help Mr. Rodriguez obtain these medications through a voucher program.
Dr. Medel suggests that Mr. Rodriguez return to the clinic after completion of therapy.
Mr. Rodriguez returns two weeks after the completion of salvage therapy for H. pylori gastritis. Through Lola, he tells you that he is completely symptom free!
Dr. Medel tells you, “You did a great job evaluating the patient, formulating a care plan for him, and perhaps most importantly, forming a continuity relationship with him over the past few months. He seems to be quite at ease with you now.”
“Before you go, let me share some evidence-based guidelines for both dyspepsia and GERD,” she adds.
Dr. Medel opens her email and sends you several links to guidelines on dyspepsia and GERD. She says, “These provide a nice framework for thinking about treating peptic ulcer disease.”
“Sounds great!” you reply.