1. 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.
Demographic Data: M, 25 y/o, male.
Subjective
Chief Complaint: “I am here today because I have some intermittently abdominal pain for
several weeks.”
HPI: 25 y/o male visiting today the office with upper abdominal pain from several weeks. Pain
associated sometimes with bloating and occasional nausea. The gnawing pain start 2 hours after
he eats and it can be relieved by antacids most of the time. Patient awake, alert, oriented to place
and time. Patient doesn’t have any pain at this time. No temperature. Patient just graduate college
and he is after exams. His preferable meals are fast foods with coke or coffee. He always eats
before bedtime. Patient does not have any history of GI disease. Patient denied any black stool.
Patient do not exercise.
Past Medical History:
Past Medical History: No medical history
Surgeries: Denies past surgeries
Hospitalization: Denies hospitalization
Medications: No medication
Allergies: Denies any known drug, food, latex or environmental allergies
Immunizations: Flu shot/8/2020, Tetanus-diphtheria booster 8/2020
Health maintenance: Dental exam 6/2020, eye exam 6/2020, physical exam 6/2020
Family History:
Paternal grandfather, living, age 75, diabetes
Paternal grandmother, living at age 73, Hypertension
Maternal grandfather, died at age 65, colon cancer
Maternal grandmother, living, age 68, Hypertension
Father, living, age 55, diabetes
Mother, living, age 54, no medical problems
Older brother, living, age 33, no medical problems
Social history:
Patient is a graduate student from law school. He is living right now in his college town
200 miles away from his parents. He is after a stressful period of time with the final exams and
graduation. He is single right now, and sexual orientation is heterosexual. He spent on learning
all his time. He wants to obtain a place in a huge law company to be a successful lawyer. He is
This study source was downloaded by 100000805030033 from CourseHero.com on 01-19-2022 21:22:28 GMT -06:00
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, marihuana smoker once in a while for recreation, when he can’t sleep. No drugs or alcohol. He is
eating all the time fast food, because he doesn’t have time for cooking. His favorite soda is coke
and he loves coffee, too.
Review of Symptoms:
Constitutional: (-) fever, (-) fatigue, (-) weight loss/gain, (-) night sweats, chills, and
changes in sleep.
HEENT: (-) sore throat, difficulty swallowing, (-) headache, dizziness, vision changes,
hearing changes, nasal congestion, sinus pain or rhinorrhea.
Lungs: (-) SOB, (-) pain, (-) cough or wheezing.
Heart: (-) chest pain, (-) dyspnea, edema, palpitations or syncope,
Abdomen: (+) pain, nausea, bloating, (-) diarrhea or constipation, vomiting
Objective
Height: 74” Weight: 180 lbs. BMI: 23.0 (Normal)
Temperature: 98.7 F, Blood Pressure: 119/79, Pulse: 73, Respiration: 18, O2Sat- 98% RA
General: 25 y/o male, AAOx3, interactive and answers appropriately
HEENT: NC/AT, PERRL, EOMI, good conjugate gaze, TMs normal bilaterally; Nares
patent bilaterally, no sinus pain or pressure, MMM, oropharynx WNL, (-) exudate or
exudate, Tonsils 1+
Neck: Normal ROM, Thyroid WNL, no masses noted
Lungs: (-) accessory muscles to breath, (-) cough, wheezing
Heart: ST, normal s1/s2, no m/r/g, no edema
Abdomen: soft, non-distended, (+) normal BS x 4, (-) masses, hernia, rebound tenderness
or guarding
Assessment
Differential Diagnosis:
1. 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. The inflammation of gastritis is most often the result of infection with
the same bacterium that causes most stomach ulcers. Regular use of certain pain
relievers and drinking too much alcohol also can contribute to gastritis. Gastritis may
occur suddenly (acute gastritis), or appear slowly over time (chronic gastritis). In
some cases, gastritis can lead to ulcers and an increased risk of stomach cancer. For
most people, however, gastritis isn't serious and improves quickly with treatment.
Weaknesses or injury to the mucus-lined barrier that protects your stomach wall
This study source was downloaded by 100000805030033 from CourseHero.com on 01-19-2022 21:22:28 GMT -06:00
https://www.coursehero.com/file/75412171/663A-week-7-discussiondocx/
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.
Demographic Data: M, 25 y/o, male.
Subjective
Chief Complaint: “I am here today because I have some intermittently abdominal pain for
several weeks.”
HPI: 25 y/o male visiting today the office with upper abdominal pain from several weeks. Pain
associated sometimes with bloating and occasional nausea. The gnawing pain start 2 hours after
he eats and it can be relieved by antacids most of the time. Patient awake, alert, oriented to place
and time. Patient doesn’t have any pain at this time. No temperature. Patient just graduate college
and he is after exams. His preferable meals are fast foods with coke or coffee. He always eats
before bedtime. Patient does not have any history of GI disease. Patient denied any black stool.
Patient do not exercise.
Past Medical History:
Past Medical History: No medical history
Surgeries: Denies past surgeries
Hospitalization: Denies hospitalization
Medications: No medication
Allergies: Denies any known drug, food, latex or environmental allergies
Immunizations: Flu shot/8/2020, Tetanus-diphtheria booster 8/2020
Health maintenance: Dental exam 6/2020, eye exam 6/2020, physical exam 6/2020
Family History:
Paternal grandfather, living, age 75, diabetes
Paternal grandmother, living at age 73, Hypertension
Maternal grandfather, died at age 65, colon cancer
Maternal grandmother, living, age 68, Hypertension
Father, living, age 55, diabetes
Mother, living, age 54, no medical problems
Older brother, living, age 33, no medical problems
Social history:
Patient is a graduate student from law school. He is living right now in his college town
200 miles away from his parents. He is after a stressful period of time with the final exams and
graduation. He is single right now, and sexual orientation is heterosexual. He spent on learning
all his time. He wants to obtain a place in a huge law company to be a successful lawyer. He is
This study source was downloaded by 100000805030033 from CourseHero.com on 01-19-2022 21:22:28 GMT -06:00
https://www.coursehero.com/file/75412171/663A-week-7-discussiondocx/
, marihuana smoker once in a while for recreation, when he can’t sleep. No drugs or alcohol. He is
eating all the time fast food, because he doesn’t have time for cooking. His favorite soda is coke
and he loves coffee, too.
Review of Symptoms:
Constitutional: (-) fever, (-) fatigue, (-) weight loss/gain, (-) night sweats, chills, and
changes in sleep.
HEENT: (-) sore throat, difficulty swallowing, (-) headache, dizziness, vision changes,
hearing changes, nasal congestion, sinus pain or rhinorrhea.
Lungs: (-) SOB, (-) pain, (-) cough or wheezing.
Heart: (-) chest pain, (-) dyspnea, edema, palpitations or syncope,
Abdomen: (+) pain, nausea, bloating, (-) diarrhea or constipation, vomiting
Objective
Height: 74” Weight: 180 lbs. BMI: 23.0 (Normal)
Temperature: 98.7 F, Blood Pressure: 119/79, Pulse: 73, Respiration: 18, O2Sat- 98% RA
General: 25 y/o male, AAOx3, interactive and answers appropriately
HEENT: NC/AT, PERRL, EOMI, good conjugate gaze, TMs normal bilaterally; Nares
patent bilaterally, no sinus pain or pressure, MMM, oropharynx WNL, (-) exudate or
exudate, Tonsils 1+
Neck: Normal ROM, Thyroid WNL, no masses noted
Lungs: (-) accessory muscles to breath, (-) cough, wheezing
Heart: ST, normal s1/s2, no m/r/g, no edema
Abdomen: soft, non-distended, (+) normal BS x 4, (-) masses, hernia, rebound tenderness
or guarding
Assessment
Differential Diagnosis:
1. 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. The inflammation of gastritis is most often the result of infection with
the same bacterium that causes most stomach ulcers. Regular use of certain pain
relievers and drinking too much alcohol also can contribute to gastritis. Gastritis may
occur suddenly (acute gastritis), or appear slowly over time (chronic gastritis). In
some cases, gastritis can lead to ulcers and an increased risk of stomach cancer. For
most people, however, gastritis isn't serious and improves quickly with treatment.
Weaknesses or injury to the mucus-lined barrier that protects your stomach wall
This study source was downloaded by 100000805030033 from CourseHero.com on 01-19-2022 21:22:28 GMT -06:00
https://www.coursehero.com/file/75412171/663A-week-7-discussiondocx/
