Description
1. Case Study Chosen: A 25-year-old male graduate student is seen in the office with the chief complaint of upper abdominal pain. He states that he noticed the pain intermittently over the past several weeks. He notices that he gets a gnawing pain about 2 hours after he eats. He also notes that he has some bloating and occasional nausea with the pain. He states that the pain is relieved by antacids most of the time.
Demographics: 25 y/o Male
SUBJECTIVE
CC: “Upper abdominal pain that has been intermittent over the past few weeks”
HPI: 25 y/o male visiting the office this morning ℅ upper abdominal pain that has lasted several weeks. Pt states that the pain is intermittent. Pt ℅ gnawing pain, bloating and nausea following eating which is relieved by OTC antacids most of the time. Pt is a college graduate student.
Past medical hx: Do you have any past medical hx?
Past surgical Hx: Do you have any past surgical hx? If so, what are the dates of the surgeries?
Family hx? Do you have any family history on either side (mother/father)?
Current Medications: Are you currently taking any medications other than the antacid post meal? Are you taking any OTC pain relievers, or OTC supplements?
Allergies: Do you have any medication, food, or chemical allergies? If so, what is the reaction?
Immunization hx: Do you currently have all of your up-to-date immunizations including flu, covid-19 + boosters?
Health Maintenance: When was your last dental, eye, physical examination?
Social HX: Are you currently employed? What are your eating habits? Do you smoke tobacco products, drink alcohol, or use illicit drugs? Where are you currently living? Who do you live with? Are you married, single? Are you sexually active?
ROS
General: Are you having any malaise, weakness, fever, chills. Have you noticed weight gains/losses of >20 lbs over the last 6 months.
Cardiovascular: Are you experiencing any chest discomfort, heaviness or tightness. Have you noticed an abnormal heartbeat or palpitations? Have you had any SOB, or had to sleep elevated on 2 pillows or more? Have you noticed swelling to feet, or passing out or nearly passing out? Any hx of heart attack/heart failure.
Respiratory: Have you noticed a cough? phlegm production, coughing up blood, wheezing, sleep apnea, exposure to inhaled substances in the workplace or home? Any exposure to TB or travel outside of the country? Any hx of asthma, COPD/emphysema or any other chronic pulmonary disease?
Gastrointestinal: Pt reports nausea and abdominal discomfort/pain. Pt reports heartburn and food intolerance. Have you had any vomiting, diarrhea, constipation, blood in the stool or black stools? Any hemorrhoids, trouble swallowing? Any hx of liver or gallbladder disease?
OBJECTIVE
General:
Take all VS of patient: BP, HR, RR, Weight, Height, BMI
Physical Exam Elements:
General: Vital signs stable, in no acute distress. Alert, well developed and well nourished.
Respiratory/chest: Auscultate the lungs for any respiratory abnormalities.
Cardiovascular:Auscultate the heart for any Cardiac abnormalities.
GI: Auscultate bowel sounds. Palpate and percuss abdomen, test with Murphys sign.
POC Testing (any Point of Care (POC) testing specifically performed in the office): N/A
ASSESSMENT
Working Diagnosis:
Functional dyspepsia – ICD – 10: K30
Functional dyspepsia (dis-PEP-see-uh) is a term for recurring symptoms of an upset stomach that have no obvious cause. Functional dyspepsia also is called nonulcer dyspepsia. Diagnosing functional dyspepsia involves ruling out other conditions that may be causing the dyspeptic symptoms. Tests to check for conditions such as stomach ulcers, stomach cancer and gallstones must first return negative before a diagnosis can be given. The symptoms of the condition can be variable, and may eventually occur much less frequently or go away completely. Functional dyspepsia is a persistent condition that is not associated with any serious complications, such as stomach ulcers or stomach cancer. Most people find their symptoms will come and go over time, depending on factors such as stress, lifestyle changes or other triggers.
(Mayo Clinic, 2022).
Epigastric pain. This is pain in the upper abdomenLinks to an external site.
Acid refluxLinks to an external site..
Bloating
Nausea after eating
Stomach pain that occurs unrelated to meals or goes away when eating.
Excessive belching
(Mayo Clinic, 2022).
Differential Diagnosis:
Gastritis, unspecified, without bleeding -ICD- 10: K29.70
Gastritis is a general term for a group of conditions with one thing in common: Inflammation of the lining of the stomach. Gastritis may occur suddenly (acute gastritis) or appear slowly over time (chronic gastritis) (Mayo Clinic, 2022).
Gnawing or burning ache or pain (indigestion) in your upper abdomen that may become either worse or better with eating
Nausea
A feeling of fullness in your upper abdomen after eating
pain in the upper abdomen just under the ribs.
loss of appetite.
Vomiting
Hiccups.
blood in the vomit.
blood in the bowel actions, if the stomach lining has ulcerated (this turns stools black and is called melaena)
weight loss.
(Mayo Clinic, 2022).
Peptic ulcer site unspecified, unspecified as acute or chronic, without hemorrhage or perforation – ICD – 10: K27.9
Peptic ulcers are open sores that develop on the inside lining of your stomach and the upper portion of your small intestine. The most common symptom of a peptic ulcer is stomach pain (Mayo Clinic, 2022).
+Feeling of fullness, bloating
+Heartburn
+Nausea
+ Pain or discomfort in the upper part of your abdomen, anywhere between your belly button and breastbone.
+ Feeling full too soon while eating a meal.
+ Feeling uncomfortably full after eating a meal.
– Vomiting.
– Belching
(Mayo Clinic, 2022).
PLAN
Diagnostic studies:
Sending patient out for the following w/ orders.
Lab: CBC, CMP, Antibody test to check for H. pylori
Lab: Breath tests to screen for abnormal bacteria in your gut.
GI: Upper endoscopyLinks to an external site.
GI: Gastric emptying studiesLinks to an external site.
Treatment: Omeprazole 20 mg oral tablet daily for 14 days (14 tabs, 0 refills).
Referrals: Gastroenterologist
Education:
Avoiding food and drinks which make the symptoms worse (caffeinated drinks or fatty food, like fast foods + alcoholic beverages)
Eating small, frequent meals as opposed to fewer, larger meals
Giving up alcohol and tobacco
Healthy diet
Acupuncture
Behavioral therapy
Health maintenance:
Dental exam (every 6 months)
Eye exam (yearly)
Physical exam (yearly)
Flu shot (yearly)
RTC: Follow up w/ provider in two weeks for checkup, lab result review and medication management. See gastro.
Table 1. Common GI Diagnosis. In addition to your SOAP note, you must also complete the following table. Upload your SOAP note and table to the discussion board.
Diagnosis
Signs/Symptoms
Gold Standard Diagnostics
Gold Standard Treatment
Acute Appendicitis
Sudden pain that begins on the right side of the lower abdomen.
Sudden pain that begins around the navel and often shifts to the lower right abdomen.
Pain that worsens with coughing, walking or making other jarring movements.
Nausea and vomiting.
Loss of appetite.
Low-grade fever that may rise as the illness worsens.
Constipation or diarrhea.
Abdominal bloating.
Gas.
(Mayo, 2023)
CT scan
(Mayo, 2023).
Urgent appendectomy
(Mayo, 2023).
Acute Cholecystitis
sudden sharp pain in the upper right side of your abdomen that spreads towards your right shoulder.
a high temperature (fever)
nausea and vomiting
sweating
loss of appetite
yellowing of the skin and the whites of the eyes (jaundice)
a bulge in the abdomen
(NHS, 2022).
Ultrasonography + Murphys sign
(NHS, 2022).
Laparoscopic cholecystectomy
(NHS, 2022).
Acute Diverticulitis
Abdominal pain, often severe.
Distended abdomenLinks to an external site. or palpable colon (you can feel it with your hand).
FeverLinks to an external site..
Nausea and vomitingLinks to an external site..
Rectal bleedingLinks to an external site..
ConstipationLinks to an external site. or, less commonly, diarrheaLinks to an external site..
(Cleveland Clinic, 2022).
CT
(Cleveland Clinic, 2022).
Hartmann procedure
(Cleveland Clinic, 2022).
Clostridium difficile Colitis (C-diff)
watery diarrhea, which can be bloody.
painful tummy cramps.
Feeling sick.
signs of dehydration, such as a dry mouth, headaches and peeing less often than normal.
a high temperature
loss of appetite and weight loss.
(CDC,2022).
Toxigenic culture
(CDC,2022).
Antibiotics such as metronidazole, vancomycin, or fidaxomicin.
(CDC,2022).
GERD
Non-burning chest pain, which is usually located in the middle of the chest and radiates to the back
Difficulty swallowing (dysphagia)
(John Hopkins, 2023).
24-h pH-monitoring
(John Hopkins, 2023).
Antacids and Alginic Acid
(John Hopkins, 2023).
Irritable Bowel Syndrome (IBS)
Abdominal pain, cramping or bloating that is related to passing a bowel movement
Changes in appearance of bowel movement
Changes in how often you are having a bowel movement
(Mayo Clinic, 2023).
Rome III criteria [1,2]
(Mayo Clinic, 2023).
Nonpharmacologic and pharmacologic approaches. Lifestyle modifications that aim to improve exercise, sleep, diet, and stress may be warranted.
(Mayo Clinic, 2023).
Duodenal Ulcer
Pain in your stomach or abdomen
Indigestion
feel very full and bloated after eating
feel like you might vomit (nauseous)
lose weight
(Health Direct, 2021).
Esophagogastroduodenoscopy (EGD
(Health Direct, 2021).
Proton pump inhibitors (PPIs)
(Health Direct, 2021).
Acute Pancreatitis
Begins slowly or suddenly in your upper abdomen
nausea (feeling sick) or vomiting.
diarrhoea.
indigestion.
a high temperature (fever) of 38C (100.4F) or above.
jaundice – yellowing of the skin and the whites of the eyes.
tenderness or swelling of the abdomen (tummy)
(NIH, 2023).
Determination of serum pancreatic enzymes
(NIH, 2023).
Surgical debridement
(NIH, 2023).
Crohn’s Disease
Diarrhea
Fever
Fatigue
Abdominal pain and cramping
Blood in your stool
Mouth sores
Reduced appetite and weight loss
Pain or drainage near or around the anus due to inflammation from a tunnel into the skin (fistula)
(Mayo Clinic, 2022).
Endoscopy with tissue biopsy
(Mayo Clinic, 2022).
Biologics : Vedolizumab (Entyvio).
(Mayo Clinic, 2022).
Ulcerative Colitis
Diarrhea, passing blood with your stool, and abdominal pain.
(NIH, 2023).
Colonoscopy and sigmoidoscopy
(NIH, 2023).
Proctocolectomy
(NIH, 2023).
2. Case Study Chosen: Case 3 – A 30-year-old male with diarrhea and abdominal cramping
Demographics: 30-year-old male
SUBJECTIVE
CC: Patient complains of 2 days of loose to watery diarrhea, 4 to 5 times a day with significant nausea and one episode of vomiting today. He has a temperature of 100.5 on presentation and an HR of 102. He also experiences abdominal cramping.
HPI: The patient’s symptoms began 2 days ago with loose to watery diarrhea occurring 4 to 5 times a day. He also reports experiencing significant nausea and one episode of vomiting today. He denies any unusual travel or recent changes in diet. The patient’s abdomen is tender, and he complains of abdominal cramping.
OBJECTIVE
General: VS: BP – within normal limits, HR – 102 bpm, RR – within normal limits, Weight – within normal limits, Height – within normal limits, BMI – within normal limits
Physical Exam Elements:
Abdominal examination: Tenderness in the abdomen, no rebound or guarding
POC Testing:
None performed during this visit
ASSESSMENT
Working Diagnosis: Gastroenteritis (ICD-10: A09)
Differential Diagnosis:
Gastroenteritis (A09)
Food poisoning
Viral gastroenteritis
PLAN
Diagnostic studies:
Stool culture to identify the pathogen causing gastroenteritis
Treatment:
Hydration: Encourage oral rehydration solutions and adequate fluid intake to prevent dehydration.
Symptomatic relief:
Antiemetics as needed for nausea (e.g., ondansetron 4 mg orally every 6-8 hours as needed)
Antidiarrheal medication (e.g., loperamide 4 mg orally after the first loose stool, then 2 mg after each subsequent loose stool; maximum 16 mg per day)
Dietary advice: Start with a bland diet (e.g., BRAT diet – bananas, rice, applesauce, toast) and gradually reintroduce normal foods as tolerated.
Follow-up: Return in 3-5 days for reevaluation of symptoms and assessment of hydration status.
Referrals:
None at this time
Education:
Educate the patient on the importance of maintaining hydration during diarrheal episodes and following a bland diet.
Health maintenance:
Encourage the patient to maintain good hygiene practices to prevent the spread of gastroenteritis.
RTC:
Return in 3-5 days for reevaluation of symptoms and assessment of hydration status.
Diagnosis
Signs/Symptoms
Gold Standard Diagnostics
Gold Standard Treatment
Acute Appendicitis
RLQ abdominal pain, anorexia, nausea, fever
Clinical assessment, CT abdomen and pelvis
Appendectomy
Acute Cholecystitis
RUQ abdominal pain, nausea, vomiting, fever
Clinical assessment, ultrasound or HIDA scan
Cholecystectomy
Acute Diverticulitis
LLQ abdominal pain, fever, altered bowel habits
CT abdomen and pelvis, colonoscopy
Antibiotics, dietary modifications
Clostridium difficile Colitis (C-diff)
Watery diarrhea, abdominal cramping, fever
Stool testing for C. difficile toxin, PCR
Antibiotics (vancomycin, fidaxomicin), supportive care
GERD
Heartburn, regurgitation, chest pain, cough
Clinical assessment, pH monitoring, endoscopy
Lifestyle modifications, PPIs, H2 blockers
Irritable Bowel Syndrome (IBS)
Abdominal pain, bloating, changes in bowel habits
Clinical assessment, Rome IV criteria
Dietary modifications, stress management
Duodenal Ulcer
Epigastric pain, nausea, vomiting, weight loss
Endoscopy, biopsy, H. pylori testing
PPIs, antibiotics for H. pylori eradication
Acute Pancreatitis
Epigastric pain radiating to the back, nausea, vomiting
Clinical assessment, elevated amylase/lipase
Hospitalization, supportive care, NPO, pain management
Crohn’s Disease
Abdominal pain, diarrhea, weight loss, fatigue
Endoscopy, colonoscopy, biopsy
Medications (corticosteroids, immunomodulators), surgery if needed
Ulcerative Colitis
Diarrhea, rectal bleeding, abdominal pain
Endoscopy, colonoscopy, biopsy
Medications (aminosalicylates, corticosteroids), surgery if needed
