Patient Information:
Initials: D.D
Age: 32 years
Sex: Female
Race: African American
S.
CC (chief complaint): Stomach pain.
HPI: D.D. is a 32-year-old African American female client who visited the facility with complaints of stomach pain. She reported that the stomach pain had lasted the last three days. She described the stomach pain as a generalized non-radiating burning ache specific in the upper abdomen. She noted accompanying symptoms that included belching, nausea and vomiting, decreased appetite, and a feeling of fullness in her stomach. She reported using antacids, which provided short-term relief. The patient rated the abdominal pain at 5/10 on the pain scale.
Location: Upper abdomen
Onset: 3 days ago
Character: generalized non-radiating burning ache.
Associated signs and symptoms: belching, nausea and vomiting, decreased appetite, and bloating.
Timing: non-specific
Exacerbating/ relieving factors: None
Severity: 5/10 pain scale
Current Medications: OTC Antacids for stomach pain. OTC Motrin for period pain and headaches.
Allergies: No food, drug, or seasonal allergies.
PMHx: No history of chronic illnesses. History of Open reduction and internal fixation (ORIF) at 19 years following a femur fracture from an RTA. Immunization is current, with the last Flu shot being 5 months ago and TT 3 years ago.
Soc Hx: The patient is a high school teacher with a Bachelor’s degree in Education. She is married and has one son, who is four years old. Her hobbies are playing volleyball and baking. She coaches the volleyball team in the high school. She occasionally takes beer but denies smoking or using drugs substances.
Fam Hx: The maternal grandmother has diabetes and HTN. Her paternal grandfather died from lung cancer at 78 years old. Her parents and siblings are alive and well.
ROS:
GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: Negative for hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: Denies discoloration, rash, or itching.
CARDIOVASCULAR: Denies chest pain, palpitations, SOB, or edema.
RESPIRATORY: Denies shortness of breath, cough, or sputum.
GASTROINTESTINAL: Positive for epigastric pain, belching, nausea, vomiting, decreased appetite, and bloating. Denies constipation, diarrhea, or tarry stools.
GENITOURINARY: Denies urinary urgency, frequency, pain during urination, or blood in urine.
NEUROLOGICAL: Denies excessive fatigue, dizziness, tingling sensations, and headaches.
MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, and stiffness.
HEMATOLOGIC: Denies anemia, bleeding, or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies a history of depression or anxiety.
ENDOCRINOLOGIC: Denies acute thirst, excessive hunger, intolerance to heat or cold, and excessive sweating.
ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Vital signs: T 98.6, RR 20, BP 120/78, P 60, SPO2 98%.
General: Female adult patient in no distress. She is appropriately dressed for the weather and neat. She is attentive, maintains eye contact, and is oriented to person, place, and time.
Cardiovascular: No cyanosis or pallor, jugular vein distension, or edema. S1 and S2 present, regular heart rhythm. S gallop sound absent. No bruits, heart murmurs, or friction rubs.
Respiratory: Respiration is effortless with no use of accessory muscles; Chest rises and falls uniformly on inspiration and expiration. On auscultation, respirations are regular and have a normal rhythm. Normal Broncho-vesicular breath sounds were present. Wheezing, rhonchi, grunting, crackles, and rales are absent.
Abdominal: On examination, bowel sounds were present and normoactive in all four quadrants, with no evidence of abdominal swelling or rebound tenderness.
Diagnostic results: Complete blood count (CBC) – Within normal limits.
A.
Differential Diagnoses (list a minimum of three differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
Primary Diagnosis- Gastritis (K29. 0): Gastritis is an inflammation of the gastric mucosa lining, which can be scattered or localized. Clinical manifestations of acute gastritis include nausea, vomiting, heartburn, anorexia, rapid onset of epigastric pain or discomfort, hematemesis, and gastric hemorrhage (Rugge et al., 2020). Patients with chronic gastritis present with nausea, vomiting, anorexia, vague reports of epigastric pain worsened by food, intolerance to fatty and spicy foods, and pernicious anemia (Shah et al., 2021). Acute gastritis was the primary diagnosis based on the patient’s report of epigastric pain, nausea, vomiting, and reduced appetite.
Helicobacter Pylori- Associated Active Gastritis (B96. 81): This is a primary infection of the stomach caused by Helicobacter pylori bacteria. Acute H.pylori infection results in a clinical syndrome marked by epigastric pain, nausea, vomiting, abdominal fullness, flatulence, and malaise (Pennelli et al., 2020). This differential is based on positive symptoms of epigastric pain, nausea, vomiting, and abdominal bloating.
Peptic Ulcer disease (PUD) (K27. 9): PUD occurs when there is a break in the mucous lining of the GI tract, and it comes into contact with HCL acid and pepsin, resulting in a gastric, duodenal, or esophageal ulcer. Abdominal pain is the classic symptom. It is described as burning, aching hunger-like in the epigastric region, possibly radiating to the back (Bereda, 2022). It occurs when the stomach is empty and relieved by food. Other symptoms are vomiting, nausea, constipation, or diarrhea. PUD is a differential based on the patient’s history of epigastric pain, nausea, and vomiting.
P.
Diagnostic studies: Esophagogastroduodenoscopy (EGD) via an endoscope with biopsy. This is the gold standard for diagnosing gastritis. It can also be used to confirm if the gastric ulcers have healed (Shah et al., 2021).
Therapeutic intervention: Oral omeprazole 20 mg once daily.
Education: Patient education focused on the risk factors for gastritis, like NSAID use, alcohol consumption, excessive caffeine intake, smoking, and corticosteroid use. The patient was educated that long-term NSAID use like Motrin has a high risk for acute gastritis (Cifuentes et al., 2022).
Referrals: Refer to a gastroenterologist if the case gets complicated.
Follow-up: The patient will be scheduled for a follow-up after four weeks. She will be asked about improvement in gastritis symptoms like epigastric pain or discomfort, nausea and vomiting, heartburn, and anorexia.
Reflection: I agree with the preceptor’s diagnosis of gastritis and treatment using Omeprazole. Omeprazole falls under Proton pump inhibitors (PPIs), which completely inhibit acid secretion and have a long duration of action. They are the most effective gastric acid blockers. I have learned that irritants like aspirin, NSAIDs, corticosteroids, alcohol, and caffeine cause acute gastritis. In a different case, I would request an H.pylori test since H.pylori infection causes gastritis. Health promotion should include advising the patient to reduce alcohol and caffeine consumption, like coffee and tea, to avoid triggering gastritis symptoms (Orgler et al., 2023). In addition, patients with gastritis should be advised to eat a well-balanced diet and quit smoking. She should be educated on stress management using complementary and alternative therapies, like relaxation and meditation techniques.
Bereda, G. (2022). Peptic Ulcer disease: definition, pathophysiology, and treatment. Journal of Biomedical and Biological Sciences, 1(2), 1–10.
Cifuentes, J. D. G., Sparkman, J., & Graham, D. Y. (2022). Management of upper gastrointestinal symptoms in patients with autoimmune gastritis. Current Opinion in Gastroenterology, 38(6), 600-606. https://doi.org/10.1097/MOG.0000000000000878
Orgler, E., Dabsch, S., Malfertheiner, P., & Schulz, C. (2023). Autoimmune Gastritis: Update and New Perspectives in Therapeutic Management. Current Treatment Options in Gastroenterology, 21(1), 64-77.
Pennelli, G., Grillo, F., Galuppini, F., Ingravallo, G., Pilozzi, E., Rugge, M., Fiocca, R., Fassan, M., & Mastracci, L. (2020). Gastritis: update on etiological features and histological practical approach. Pathologica, 112(3), 153–165. https://doi.org/10.32074/1591-951X-163
Rugge, M., Sugano, K., Sacchi, D., Sbaraglia, M., & Malfertheiner, P. (2020). Gastritis: An update in 2020. Current Treatment Options in Gastroenterology, 18, 488-503.
Shah, S. C., Piazuelo, M. B., Kuipers, E. J., & Li, D. (2021). AGA Clinical Practice Update on the Diagnosis and Management of Atrophic Gastritis: Expert Review. Gastroenterology, 161(4), 1325–1332.e7. https://doi.org/10.1053/j.gastro.2021.06.078