The patient most likely suffers from Acute gastritis. This is due to the various symptoms she displays when diagnosed. Conditions such as nausea, abdominal pain, and indigestion are some of the common symptoms of Acute Gastritis (Bickley & Szilagyi, 2012). The case study shows that the patient displays the signs mentioned above among others such as bloating, heartburn and decreased bowel movement. Besides, the patient claims that the pain worsens after eating fried food which is also a common symptom of Acute gastritis. Moreover, she reports that she regularly uses Motrin and Aleve which are nonsteroidal anti-inflammatory drugs (NSAID) that are said to cause Acute gastritis as stated by Rogoveanu et al. (2015). Another cause of the disease is extreme stress she says to have due to work and family. To confirm the diagnosis, the doctors will need to conduct a blood test, an endoscopy of the stomach lining, carry out a breath test to detect the presence of H. Pylori infection and a stool test to check for the presence of the virus in the stool (Elseweidy, 2017).
The second likely diagnosis is Gastroesophageal reflux disease (GERD) which is the most significant biological cause of heartburn. Its common symptoms include burping, regurgitation of food and heartburn which are experienced by the patient. However, she does not display other signs like water brash, cough, and aspiration. One of the major factors that trigger the disease includes fatty foods. The patient claims to have increased abdominal pain after eating fried food. Other causes include smoking, which the patient denies, alcohol that she reports to take only during social occasions, caffeine, and chocolate. According to (Goolsby & Grubbs (2018), the doctors will need to carry out endoscopy to give direct visualization of the esophagus and Ambulatory esophageal pH monitoring to help identify the association between symptoms and reflux when confirming the diagnosis.
The least likely diagnosis is Pancreatitis. In as much as the patient displays some of its symptoms like nausea, vomiting, and abdominal pain, it is least possible that the patient is infected with the disease because those are the general characteristics of any abdomen-related disorders. Besides, some of its outstanding signs like shallow respirations, ascites, tachycardia, and postural hypertension are not displayed by the patient. On the other hand, the primary cause for the disorder is alcohol abuse, but the patient reports only to take alcohol during social occasions. Other reasons include hereditary Pancreatitis, toxins, drugs, surgery, and trauma; all of which are absent in the patient’s case. To confirm the diagnosis, the doctors may need to carry out various tests such as ultrasound imaging to perceive an inflamed pancreas, gallstones and biliary hindrance (Goolsby & Grubbs, 2018). Other criteria include a CT scan, white blood count (WBC) and supine.
The diseases mentioned above occur in the abdominal region; hence they have a similar physical examination. Goolsby & Grubbs (2018) state that the abdominal examination begins with inspection then auscultation followed by percussion and finally palpation. The doctor should start with inspection for scars, contours, symmetry, and discolorations. They should then carry out auscultation to hear entire bowel sounds. Goolsby & Grubbs (2018) further suggests that after auscultation, the physician should percuss for areas of dullness indicating fluid or solid instead that air. Finally, both light and deep palpations should be conducted to detect tenderness or tumors. The doctors should also ask about the patient’s medical and family history of jaundice, liver disease, hepatitis, and fever before performing any specific diagnosis (Goolsby & Grubbs, 2018).
The best plan of care for the diseases is to stop the usage of the causal factors of the particular disorder. However, in severe cases, additional antibiotics may be administered. Elseweidy (2017) states that histamine blockers like ranitidine may be used as antacids. On the other hand, the patient may resort to natural factors as medication for gastritis. Phenolic compounds like Tannins and Flavonoids have significant healing effects. They are known for their antioxidant and anti-inflammatory actions. Also, fresh vegetables, fruits, and curcumin are also common for their essential effect on ulcers due to their flavonoids content (Elseweidy, 2017).
Bickley, L., & Szilagyi, P. G. (2012). Bates’ guide to physical examination and history-taking. Lippincott Williams & Wilkins.
Elseweidy, M. M. (2017). Brief Review on the Causes, Diagnosis and Therapeutic Treatment of Gastritis Disease. Altern Integr Med, 6(231), 2.
Goolsby, M. J., & Grubbs, L. (2018). Advanced assessment interpreting findings and formulating differential diagnoses. FA Davis.
Rogoveanu, O. C., Streba, C. T., Vere, C. C., Petrescu, L., & Trăistaru, R. (2015). Superior digestive tract side effects after prolonged treatment with NSAIDs in patients with osteoarthritis. Journal of medicine and life, 8(4), 458.