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 ...