Objective: Patient appears well-groomed and devoid of nervousness or anxiety. Vital signs are within normal limits (WNL), except for mild fever. Abdomen: Normal bowel sounds, no rebound or guarding, no masses, presence of mild epigastric tenderness on palpation.
Gastritis
Gastroesophageal Reflux Disease (GERD)
Irritable Bowel Syndrome (IBS)
The primary diagnosis for this case is gastritis. Based on the subjective assessment findings, it is apparent that the symptoms described by the patient are consistent with gastritis. Additionally, the patient has a history of gastritis, hence making it a primary diagnosis. GERD may be excluded as a primary diagnosis since GERD-related pain is usually localized in the chest (McPhee et al., 46). As the patient describes, the pain in dull and affects the general abdominal region. Likewise, Irritable Bowel Syndrome may be excluded since; it is usually accompanied by various classical symptoms such as constipation, nausea, vomiting, diarrhea and bloating-which are absent in this scenario (McPhee et al., 57).
Plan: In order to gain a deeper and more accurate insight into the diagnosis, it is pretty essential to undertake advanced diagnostic and testing procedures. These include; blood or stool test for H. pylori to determine the presence of the bacteria, endoscopy (for the purposes of detecting inflammation as well as H. pylori) as well as an X-ray of the upper digestive system to detect the possibility of abnormalities. Based on the findings of the subjective assessment as well as the patient medical history, gastritis, GERD or Irritable Bowel Syndrome feature predominantly as the possible diagnoses. The treatment plan for this patient includes both pharmacological and non-pharmacological approaches. The use of antibiotics’ combinations such as amoxxilin and clarithromycin or metronidazole can go a long way in killing the bacterium (H. pylori) (Neumann et al., 535). On the other hand, the use of proton-pump inhibitors is usually considered first line treatment for acid reflux and in this regard, the administration of proton pump inhibitors such as omeprazole and lansoprazole can help in preventing acid production, hence relieving the acid reflux and its accompanying discomforts (Neumann et al., 535). Considering that any of these gastrointestinal conditions are worsened or triggered by lifestyle aspects, patient education- as a non-pharmacological approach is crucial (Hunt & Guido, 26). Patient education would focus on dietary modifications and restrictions (reducing amount of food eaten at once, desisting intake of irritating foods and avoiding alcohol) as well as stress management and coping. A post-intervention follow-up is equally important not only for the purposes of monitoring patient’s progress, but also ensuring adherence to medications and discharge instructions/advice. As such, a follow-up would be done after every two weeks, through bi-weekly clinical appointment, until the symptoms persist.
Reflection notes: One of the surprising aspects with regard to this case is that gastrointestinal conditions usually manifest in pretty overlapping symptoms. It is also quite clear that in the absence of proper and comprehensive patient assessment, one may easily mid-diagnose a gastrointestinal condition. This underscores the need for exhausting all assessment and diagnostic approaches in order to achieve the most probable diagnosis. In the event of a similar patient evaluation, one of the things that I would do differently is to involve a parent, a guardian or surrogate. Considering that the patient falls within the pediatric age-bracket, it would be appropriate to assume that the patient lacks adequate self-expression and communication skills, hence compromising the quality of the subjective assessment. In this regard and in order to conduct an optimal and satisfactory subjective assessment, I would consider the involvement of a parent, a guardian or a surrogate who bears a sound understanding of the patient’s medical history.
Works cited
Hunt, Richard H., and Guido Tytgat, eds. Helicobactor Pylori: Basic Mechanisms to Clinical Cure 2002. Springer Science & Business Media, 2013.
McPhee, Stephen J., Maxine A. Papadakis, and Lawrence M. Tierney, eds.Current medical diagnosis & treatment 2010. New York:: McGraw-Hill Medical, 2010.
Neumann, William L., et al. "Autoimmune atrophic gastritis—pathogenesis, pathology and management." Nature Reviews Gastroenterology and Hepatology 10.9 (2013): 529-541.
