Case Study 1: A 25-year-old male graduate student who complains of upper abdominal pain

 

Demographic data: 25 years old male

 

SUBJECTIVE

 

Chief Complaint: The 25-year-old graduate says he has been experiencing intermittent abdominal pain for some weeks now.

 

HPI: The 25-year-old student visited the office complaining of upper abdominal pain that has affected him for several weeks. He notes that the pain is associated with accessional nausea and bloating. He experiences the pain sometimes after eating which he relieves with antacids. An examination of the patient shows he is awake oriented to time and place, and alert. Now, he does not report any pain. He says his most preferred meals are fast foods accompanied by coffee or cola and eats some minutes before bedtime. No history of GI is reported, does not exercise, and denies black stool.

 

Past medical history

 

· Medical history: No past medical history.

 

· Surgeries: no past surgery

 

· Allergies: The patient has no history of food, environmental, or drug allergies.

 

Family History:

 

· Grandfather had diabetes at the age of 75

 

· Grandmother had hypertension at the age of 72 years

 

· Maternal grandfather had colon cancer and died at the age of 66 years.

 

· Father at the age of 50 years has diabetes.

 

· Mother has no medical condition.

 

Social history

 

The patient is a graduate student residing in a college town some miles away from his parents. He notes that he went through a rough and stressful experience during the exams and graduation. He is not engaged and looking for a job in one of the leading law firms. Do not smoke or take drugs or alcohol. His meals are fast food, citing a lack of time to cook.

 

Symptoms review:

 

Constitutional: negative fever, weight loss or gain, fatigue, night chills, and sweats.

 

Abdomen: positive nausea, pain, and bloating, no vomiting, constipation, and diarrhea.

 

OBJECTIVE

 

Height: 6.7 inches, weight 184 lbs., BMI 24.0

 

Vitals: Temperature 98.4, BP 119/73, RR 18/min

 

Abdomen: non-distended, soft, negative rebound tenderness, guarding, or masses.

 

ASSESSMENT

 

Differential Diagnosis

 

Gastritis:

 

Refers to a condition leading to inflammation of the stomach lining and is caused by a bacterium that also causes ulcers. Drinking of alcohol and use of some painkillers may lead to this disease. Not a serious condition and improves with treatment. Symptoms include bloating, nausea, and stomach pain (Rugge et al., 2020).

 

Peptic ulcer-ICD-10: K27.9:

 

Occurs as open sores within the stomach lining and may also occur on the upper lining of the small intestine. Characterized by stomach pain and is caused by Helicobacter pylori and continued use of NSAIDs. Spicy meals and stress are other associated factors that lead to peptic ulcers. Positive signs include bloating, nausea, and stomach pain. Negatives include belching and heartburn (Lanas & Chan, 2017).

 

Working Diagnosis

 

Functional Dyspepsia-ICD-10: K30:

 

The process involved eliminates conditions associated with dyspeptic symptoms. The doctor checks gallstones, stomach cancer, and ulcers which must be negative before giving a diagnosis. Blood tests are also needed to check for the presence of H. pylori. Functional dyspepsia has no cure although management is done through medication and lifestyle change. Positive signs include upper abdominal pain, bloating, and nausea. Negatives are excessive belching and heartburn (Ford et al., 2020).

 

Plan

 

Diagnostics needed

 

Lab: CMP, CBC, antibody test for H. pylori.

 

Pharmacological: Administer 20 mg omeprazole tablet taken every day for two weeks.

 

Non-pharmacological: dietary management, acupuncture, lifestyle modification, medical meal.

 

Education: Stop the intake of foods that worsen the condition. Reduce intake of alcohol and take small and frequent meals.

 

RTC: follow up after 14 days for lab results and checkup.

 

Table 1. Common GI Diagnoses

 

DIAGNOSIS

 

SIGNS/SYMPTOMS

 

GOLD STANDARD DIAGNOSTICS

 

GOLDEN STANDARD TREATMENT

 

Acute Appendicitis

 

Nausea, loss of appetite, lower abdominal pain, vomiting

 

Computer tomography (CT)

 

Appendectomy

 

Acute Cholecystitis

 

Intense pain in the upper right belly, vomiting, nausea, belly bloating, jaundice, light-colored and loose stool, and back pains.

 

Cholescintigraphy

 

early laparoscopic cholecystectomy

 

Acute Diverticulitis

 

Tenderness of the abdomen, chills and fever, vomiting and nausea, loss of appetite, and bloating

 

Computer tomography (CT)

 

Hartmann’s procedure

 

Clostridium difficile Colitis (C-diff)

 

Watery diarrhea, painful tummy cramps, fever, loss of weight and appetite, dehydration, less peeing, and headaches.

 

Stool Test for toxigenic culture and tissue culture assay to test toxins.

 

Oral vancomycin

 

GERD

 

Chest burning sensation (heartburn), chest and upper belly pain, throat lump, dysphagia.

 

24-h pH-monitoring

 

PPI therapy (Proton pump inhibitors)

 

Irritable Bowel Syndrome (IBS)

 

Abdominal cramping and pain, constipation, diarrhea, swelling of the stomach, bloating, and occasional need for bowel movement.

 

Rome III criteria

 

No definitive treatment but can be managed by rifaximin, eluxadoline, or alosetron pharmacological agents.

 

Duodenal Ulcer

 

Nausea, weight loss, black and bloody stool, vomiting, loss of appetite, and burping.

 

Esophagogastroduodenoscopy (EGD)

 

Proton pump inhibitors (PPIs) 

 

Acute Pancreatitis

 

Upper belly pain, tender belly, rapid pulse, vomiting, upset stomach, and rapid pulse.

 

Determination of serum pancreatic enzymes.

 

laparotomy and immediate surgical debridement

 

Crohn’s Disease

 

Fever, fatigue, watery diarrhea, loss of weight, loss of appetite, belly experiences cramp pain.

 

Endoscopy

 

Surgery

 

Ulcerative Colitis

 

Abdominal pain, cramping, fever, diarrhea, weight loss, frequent need for bowel movement.

 

Colonoscopy and sigmoidoscopy

 

Proctocolectomy

 

References

 

Ford, A. C., Mahadeva, S., Carbone, M. F., Lacy, B. E., & Talley, N. J. (2020). Functional dyspepsia.  The Lancet,  396(10263), 1689-1702.

 

Lanas, A., & Chan, F. K. (2017). Peptic ulcer disease.  The Lancet,  390(10094), 613-624.

 

Rugge, M., Sugano, K., Sacchi, D., Sbaraglia, M., & Malfertheiner, P. (2020). Gastritis: An update in 2020.  Current Treatment Options in Gastroenterology,  18, 488-503.

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