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Epigastric Case

The document presents a case of a 45-year-old male, Abdirahman Ali Osman, who has been experiencing epigastric pain for two weeks, characterized as burning pain that worsens after eating spicy food and at night. The patient's history reveals no significant gastrointestinal issues, and he has a provisional diagnosis of Peptic Ulcer Disease (PUD) or gastritis, with differential diagnoses including GERD and chronic gastritis. His social history indicates smoking and a high intake of spicy foods and coffee.

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Abdulkadir Yaxye Osman
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37 views3 pages

Epigastric Case

The document presents a case of a 45-year-old male, Abdirahman Ali Osman, who has been experiencing epigastric pain for two weeks, characterized as burning pain that worsens after eating spicy food and at night. The patient's history reveals no significant gastrointestinal issues, and he has a provisional diagnosis of Peptic Ulcer Disease (PUD) or gastritis, with differential diagnoses including GERD and chronic gastritis. His social history indicates smoking and a high intake of spicy foods and coffee.

Uploaded by

Abdulkadir Yaxye Osman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Epigastric case

Personal Data

• Name: Abdirahman ali osman.


• Age: 45 years
• Sex: Male
• deyniile
• Marital status: Married
• Occupation: Shopkeeper

Presenting Complaint

epigastric pain for 2 weeks.”

History of Present Illness (HPI)

SOCRATES for pain:

• S (Site): Epigastric region


• O (Onset): Gradual, started 2 weeks ago
• C (Character): Burning pain
• R (Radiation): Occasionally radiates to the back
• A (Associated symptoms): Nausea, occasional vomiting, bloating, and heartburn. Pain
worsens after eating spicy food and at night when lying down; relieved by antacids and
milk.
• T (Timing): Mostly after meals, worse at night
• E (Exacerbating/Relieving factors): Exacerbated by coffee and spicy food; relieved by
antacids
• S (Severity): 6/10

Negative Symptoms (GI system)

• No hematemesis (no blood in vomit)


• No melena (no black tarry stools)
• No hematochezia (no fresh blood in stool)
• No dysphagia (no difficulty swallowing)
• No odynophagia (no painful swallowing)
• No jaundice
• No constipation or diarrhea

Review of Further Systems

• Cardiovascular system: No chest pain, no palpitations, no orthopnea, no paroxysmal


nocturnal dyspnea.
• Respiratory system: No cough, no wheeze, no hemoptysis, no shortness of breath.
• Genitourinary system: No dysuria, no frequency, no hematuria, no flank pain.
• Neurological system: No headache, no dizziness, no weakness, no loss of consciousness,
no visual problems.
• Musculoskeletal system: No backache (other than mild pain radiating from
epigastrium), no joint pain or swelling.

Past Medical History

• No history of peptic ulcer disease diagnosed previously


• No history of diabetes mellitus or hypertension
• No history of chronic medication use (NSAIDs, steroids)

Past Surgical History

• No previous abdominal surgery

Drug History

• Occasionally takes over-the-counter antacids


• No known drug allergies

Family History

• Father: Hypertension and diabetes mellitus


• Mother: Healthy
• No family history of gastrointestinal malignancy
Social History

• Smokes 10 cigarettes/day for 10 years


• Drinks coffee regularly (4–5 cups/day)
• Diet: Spicy food intake common
• Married, lives with family

Provisional Diagnosis

• Likely Peptic Ulcer Disease (PUD) / Gastritis

Differential Diagnosis

1. Gastroesophageal reflux disease (GERD)


2. Chronic gastritis (e.g., H. pylori infection)
3. Peptic ulcer disease (gastric or duodenal)

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