Gastrointestinal Disorders (Case Study Sample)

Gastrointestinal Case Study
Name
Institutional affiliation
Course
Date
Problem Identification through Subjective Data
Chief Complain (CC): Abdominal pains that feels like “severe cramps”
History of presenting illness (HPI):
Ms. S is a 40 years old female who presented with complains of abdominal pain in the primary care office. The patient said that the pain has been on and off for the last one month. The pain is located on the upper abdomen and comes up in ‘episodes’ or ‘attacks’. She said that the pain lasts for about 4 hours and at times the pain occur at night waking her up. The pain is described as ‘severe cramps’ that at tomes shoots to her heart, back and the shoulders. It is usually associated with vomiting. The patient says that she has tried taking antacids without getting any relief. She says that the pain goes away on its own. The patient reports of having flatulence, and denies having fevers and reported loose bowel movement (LBM) today.
Past medical History (PMH): Not provided
Medications: none
Allergies: Not provided
Surgical: Not provided
Health Maintenance: Not provided
Immunizations: Not provided.
FH: Not provided
SH: reports social ETOH, 1-2 drinks per week, denies smoking
Review of Systems (ROS)
Skin: Intact
HEENT/Mouth: Negative
Cardiovascular: Negative
Respiratory: Negative
Gastrointestinal: Reports Loose Bowel Movement (LBM) today
Genitourinary: Negative
Musculoskeletal: Negative
Endocrine: Negative
Neurological: Negative
Psychiatric: Negative
Objective Data
Physical Examination
Vital signs: Temperature 98.6F. P-72 RR-18 BP-118/76 SPO2-98% on room air, BMI-32
General: A well-groomed female who is well oriented to time, place and person. She is also cooperative
Skin: The skin is warm and dry.
HEENT: The Pupils are equal, round, Reactive to Light and normal Accommodation (PERRLA). Extra-ocular muscles movements are intact (EOMI) and the sclera is anicteric
Throat/mouth: Not provided
Neck: Not provided
The chest/lungs: Respirations easy/non labored. Lungs are Clear To Auscultation Bilaterally (CTAB)
Cardiovascular system: Unremarkable
Respiratory system: Not provided
Abdominal exam: abdomen soft, mild epigastric discomfort to deep palpation, murphy sign negative.
Rectal exam: guaiac negative stool (No blood in stool), no hemorrhoids.
Differentials Diagnosis
Peptic ulcer disease (ICD-10 K27.9):
As a generic name, the peptic ulcer disease includes ulcers in that may be gastric or duodenal. It involves disruption of the protective mucosa of the stoma or the duodenum where the underlying tissues are damaged by the hydrochloric acid and pepsin. Infection by a bacterium called Helicobacter bacteria and destruction by NSAIDs medication is two known etiologic factors. Due to this break there is an imbalance between the mucosal protective factors and the ulcer worsening factors that are produced from the stomach such as the acid and the digestive enzyme, pepsin (Dumpy, Win land-Brown, Porter, & Thomas, 2015).
A certain portion of population develops idiopathic ulcers that are Pylori negative and not related to NSAIDs use. Pain due to PUD is usually intermittent according to the pattern of release of the hydrochloric acid, food intake and antacids. Some patients also get nocturnal pain which coincides with the circadian rhythm of acid secretion stimulation. Patients with duodenal ulcer experience relief after eating while those with gastric ulcer tends to have more pain after eating and the pain is relieved by hunger. Presence of vomiting, anorexia and weight loss indicates a complicated disease. For gastric ulcer, the vomitus may contain blood (hematemesis) while duodenal ulcer is associated with melena (Kuna et al., 2019).
Gastroesophageal reflux disease (ICD-10 K21.9):
Flow of stomach content back to the esophagus is at times a normal process. However, continuous exposure of the esophageal mucosa lining to the deleterious effect of the stomach content leads to breakdown of the mucosa leading to the symptoms of (GERD). Relaxation of the lower esophageal