Posted: January 26th, 2023

Patient With Sudden Onset of Intermittent Mid-Epigastric Pain

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Patient With Sudden Onset of Intermittent Mid-Epigastric Pain

PR is a 35-year-old female who presents with a sudden onset of intermittent mid-epigastric pain that started 4 weeks ago. Pain is 6/10 on the pain scale and described as burning that worsens after she eats Mexican food and when she is lying down. She has never experienced this before. PR reports that she has been taking over the counter (OTC) antacids that seemed to help at first, but now they provide no relief. She reports associated regurgitation and feeling of fullness all the time and this morning she had a sore throat.

Past Medical History

• Anaphylactic reaction to penicillin Medications

• OTC antacids

Family History

• Noncontributory

Social History

• Occupation: Elementary school teacher (10 years)

• Nonsmoker

• Denies illicit drug use

• Consumes wine two to three times per month •

Regular exercise

Physical Examination

• Weight: 145 lbs.; blood pressure: 128/72; pulse: 80; respiration rate: 18; temperature: 98.7 °F

• General: Calm, cooperative, in no apparent distress

• Eyes: Pupils equal, round, reactive to light

• Ears: Tympanic membranes clear

• Nares: Without nasal septal deviation; pharyngeal mucosa pink and moist

• Throat: Oropharynx without edema, erythema, tonsillar enlargement, lesions

• Abdomen: Nondistended, soft, round, nontender; normoactive bowel sounds in all quadrants

Discussion Questions

1. What are the top three differential diagnoses for PR?

2. What diagnostic tests, if any, are required for PR?

3. What pharmacological, nonpharmacological, and/or nutraceutical therapies should be prescribed for PR?

4. The results from PR’s H. pylori test returned positive. What treatment should be added to her plan of care?
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Differential Diagnoses
Gastroesophageal Reflux Disease (GERD)
One of the top three differential diagnoses for PR’s symptoms is Gastroesophageal Reflux Disease (GERD). GERD is a common condition that is characterized by symptoms of heartburn and regurgitation, which are consistent with PR’s symptoms (Liu, Lin, & Hsieh, 2020). The burning pain that worsens after she eats Mexican food and when she is lying down, as well as her use of OTC antacids, further support this diagnosis (Liu et al., 2020).
Peptic Ulcer Disease (PUD)
Another potential differential diagnosis for PR is Peptic Ulcer Disease (PUD). PUD is a condition in which sores develop in the lining of the stomach or small intestine (Liu et al., 2020). The pain in the mid-epigastric area and regurgitation that PR is experiencing could be a result of an ulcer in the stomach or duodenum (Liu et al., 2020).
Gastritis
The third differential diagnosis to consider for PR is Gastritis. Gastritis is a general term for inflammation of the stomach lining, which can cause a variety of symptoms, including abdominal pain, nausea, and vomiting (Souza et al., 2020). PR’s symptoms of pain, regurgitation, and feeling of fullness are consistent with gastritis (Souza et al., 2020).
Diagnostic Tests
To confirm a diagnosis and determine the underlying cause of PR’s symptoms, the following diagnostic tests may be required:
Upper Gastrointestinal Endoscopy (EGD)
An Upper Gastrointestinal Endoscopy (EGD) is a diagnostic test in which a flexible tube with a camera on the end is used to visualize the inside of the upper gastrointestinal tract (Souza et al., 2020). EGD can help determine if PR has an ulcer, inflammation, or other abnormalities in the stomach or duodenum (Souza et al., 2020).
H. pylori Test
A test for Helicobacter pylori (H. pylori) may also be required. H. pylori is a bacterium that is commonly found in the stomach and is associated with gastritis and PUD (Souza et al., 2020). A positive result from PR’s H. pylori test would indicate that she is infected with the bacterium, which could be contributing to her symptoms (Souza et al., 2020).
Pharmacological, Nonpharmacological, and Nutritional Therapies
Pharmacological Therapy
To treat PR’s symptoms, a proton pump inhibitor (PPI) may be prescribed. PPIs work by decreasing the amount of acid produced in the stomach, which can help relieve symptoms of heartburn and regurgitation (Liu et al., 2020).
Nonpharmacological Therapy
In addition to medication, PR may benefit from nonpharmacological therapy such as lifestyle modifications. This could include avoiding foods that trigger her symptoms, avoiding eating late at night, and losing weight if needed (Liu et al., 2020).
Nutritional Therapy
PR may also benefit from

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