Dyspepsia (Gastritis) Case Studies

JN/DIP.MED.
ASSIST/CUCMS
CASE STUDIES
STUDENT NAME : JESICA NURIN ANAK GRAMAN

NO. MATRIC : DMA 1411-5544
SUBJECT : COMMUNITY HEALTH POSTING 1 (OPD
JENJAROM)
CODE SUBJECT : MPCH 2042
TOPIC : DYSPEPSIA (GASTRITIS)
DATE OF POSTING : 29 AUGUST 2 SEPTEMBER 2016
SEMESTER / YEAR : SEMESTER 4 YEAR 2
BATCH : 3
CLINICAL INSTRUCTOR NAME : TUAN HAJI MOHD. ABDUL
LATIFF BIN MOHD. SABRI
JN/DIP.MED.ASSIST/CUCMS
CASE STUDIES
CONTENTS
NO.
CONTENT
PAGE
1.1 PATIENT PROFILE
1.2 INTRODUCTION
1.3 HISTORY OF PRESENT ILLNESS
1.4 PAST HEALTH HISTORY
1.5 FAMILY HISTORY
1.6 SOCIAL HISTORY
1.7 HEALTH MAINTANENCE ACTIVITIES
1.8 PHYSICAL ASSESSMENT
5-6
1.9 INVESTIGATION
1.10 DIFFERENTIAL DIAGNOSIS
1.11 DIAGNOSIS
1.12 MANAGEMENT AND TREATMENT
1.13 DISCUSSION
1.14 CONCLUSION
1.15 PROGNOSIS
1.16 PATHOPHYSIOLOGY
1.17 REFERENCES
CASE STUDIES
1.1
PATIENT PROFILE
R/N: 0011
Gender: Female
Race: Malay
Religion: Islam
Date of birth: 29 March 2002
Age: 14 years old
Weight: 50 kg
Height: 151 cm
BMI : 21.9 kg/m2
1.2
INTRODUCTION
Gastritis is the inflammation of the lining (mucosa) of the stomach.

Theres 3 type of gastritis such as acute erosive gastritis, chronic
gastritis and atrophic gastritis. Acute erosive gastritis is caused by
ingesting excess alcohol or other irritating or corrosive substances,
resulting in vomiting. Chronic gastritis is associated with smoking and
chronic alcoholism and may be caused by bile entering the stomach
from the duodenum, but most cases are caused by the bacterium
Helicobacter pylori. Atrophic gastritis is in which the stomach lining is
atrophied, may succeed chronic gastritis but may occur spontaneously
as an autoimmune disease, often in association with pernicious
anaemia, and is strongly associated with the development of gastric
cancer.
1.3
HISTORY OF PRESENT ILLNESS
She complaints had epigastric pain but then, radiated to left hip. Last
night, she had eating spicy food. After a few minutes, she had go to toilet
due to stomach ache but didnt produces any stool. The pain still not
relief until she got to go to clinic today. No nausea and vomiting. No
fever.
3
CASE STUDIES
1.4 PAST HEALTH HISTORY

i.
Past medical history : Had diagnosed gastritis at age 12 years
old. No allergic history recorded.
ii.
Past surgical history : No surgery history recorded.
iii.
Gynaecological history : Not yet having menses.
iv.
Psychiatric history : No psychiatric history recorded.
1.5
FAMILY HISTORY
Convention :
Male
Female
Had heart disease

Had heart disease and chronic diseases
Had migraine
Had gastritis
Died at age 43 due to Pulmonary Tuberculosis
Indicates patient
1.6
a.
b.
c.
SOCIAL HISTORY
Born at Hospital Banting. Lives at Bukit Canggang.
Non- smoker.
School at SM(A) Tahfiz Harapan, Jenjarom. Attend school as Form
2 student.
d. No allergic history recorded.
e. Her mother worked as Supervisor at ISF, Dengkil.
f. Her father worked as architect but died in year 2010 due to
suffered from Pulmonary Tuberculosis.
CASE STUDIES
1.7 HEALTH MAINTANENCE ACTIVITIES

a. Active in sports. Attend badminton and netball at school.
b. Doing physical warm up exercise during PJK (Pendidikan Jasmani
dan Kesihatan) only once every week.
c. Last night, sleep pattern keep changing due to stomach ache.
1.8 PHYSICAL ASSESSMENT
1. Vital sign been taken results ;
i.
Blood pressure : 108/67 mmHg.
ii.
Pulse rate : 75 bpm.
iii.
Respiration rate : 18 per min.
iv.
Temperature : 36.8 C.
v.
Pain score : 6/10.
vi.
GCS score : 15/15.
vii. SPO2 : 100%.
viii. ECG : Sinus rhythm.
2. On Examination : Alert, pink, CRT<2 sec.
3. General condition : In pain, discomfort.
4. Chest examination: Thorax and lung.
i.
Inspection : No scars, no hematoma.
ii.
Palpation : Chest movement symmetry, no swelling.
iii.
Percussion : Resonance.
iv.
Auscultation : Lung clear, no crepitus, no ronchi.
5. Cardiovascular system examination.
i.
Inspection : No spider navy, no bruises, no scars.
ii.
Palpation : No cardiomegaly, apex beat palpable, chest
movement symmetry.
iii.
Auscultation : Dual rhythm no murmurs (DRNM).
6. Peripheral vascular system examination.
i.
Inspection : Skin pink, conjunctiva pink.
ii.
Palpation : Capillary refill test <2 sec.
7. Abdomen examination.
i.
Inspection : No ascites, no spider navy, no distented.
ii.
Palpation : Tenderness on epigastric region and pain score
6/10, no guarding.
iii.
Percussion : Resonance.
iv.
Auscultation : Bowel sound passive.
8. Central nervous system examination.
i.
Inspection : Verbal active, no slurred speech, good memory.
9. Musculoskeletal system examination.
i.
Inspection : Patient claimed no fracture history, no deformities.
ii.
Palpation : No tender, no abnormalities on bony area.
5
CASE STUDIES
iii.
10.
i.
ii.
Special maneuvers : Bicep and triceps jerk : Both good

responds, knee and ankle jerk : Both good responds.
Lower extremities examination.
Inspection : No deformities, no scar.
Palpation : No pitting oedema, no tenderness.
1.9 INVESTIGATION
i.
Full Blood Count. To examine the abnormalities in blood volume
such as red blood cell, haematocrit, mean corpuscle volume,
haemoglobin, platelet, mean corpuscle haemoglobin, white
blood cell, mean corpuscle haemoglobin concentration, white
differential count and mean platelet volume.
ii.
Esophagogastroduodenoscopy (EGDS). To examine the inside
of the esophagus, stomach, and duodenum with an endoscope,
which is guided into the mouth and throat, then into the
esophagus, stomach, and duodenum.
iii.
Abdomen X-ray. To identify other abnormalities at abdomen
area.
iv.
Helicobacter pylori test. To identify if theres any infection that
caused by Helicobacter pylori in gaster.
1.10 DIFFERENTIAL DIAGNOSIS
i.
Dyspepsia (gastritis)
ii.
Cholecystitis.
iii.
Pancreatitis.
iv.
Salphingitis.
v.
Oophoritis.
1.11 DIAGNOSIS
Dyspepsia (gastritis)
CASE STUDIES
1.12 MANAGEMENT AND TREATMENT

i.
Take vital sign such as blood pressure, temperature and pulse
rate.
ii.
Take complaint of, family history and history of present illness.
iii.
Do physical assessment such as abdominal palpation and
inspection.
iv.
If necessary, do full blood count, helicobacter pylori test and
abdomen x-ray.
v.
If patient condition severe, rest the patient and give Mixture
Trisilicate 10 mg stat.
vi.
After the patient condition stabilized, discharge the patient.
vii. Give medication such as antacid, Mixture Magnesium Trisilicate
10 ml and antispasmodic, Tablet Prochlorperazine Maleate
5mg.
viii. If symptom persists, tell the patient to come to nearest clinic for
further investigation.
1.13 DISCUSSION
Acute gastritis is a damage to the gastric mucosa due to medication,
irritants, infections, uremia and stress. Etiological factors for acute
gastritis vary in developed and developing countries. In developed
countries, drugs like Aspirin to prevent arterial thrombosis or NSAID for
relief of the pain of arthritis are widely consumed by elderly and the
commonest cause of acute gastritis. Drug induced mucosal damage is
predominantly in the antrum. In acute gastritis, the gastric mucosa is
intensely congested both in the body and antrum. The mucosal biopsy
shows degenerative changes in the surface epithelium with mucus
depletion and heavy infiltration with neutrophils.
1.14 CONCLUSION
In my conclusion, gastritis is actually can be reliefs quickly just with the
treatment and the food we ate. Parents should care for their child diet by
not giving a high acidic value food and beverages such as sour fruit,
spicy food and drinks that containing alcohol.
CASE STUDIES
1.15 PROGNOSIS
Gastritis is a common condition and can be acute or chronic. The good
news is that in the most people, gastritis improves quickly after the
caused is diagnosed and treatment is started. In many people, there is
no precipitating factor such as alcohol or NSAIDs (non-steroidal antiinflammatory drugs). In most of these cases, outlook for a full recovery is
very good with treatment. With appropriate treatment, avoiding
precipitating factor such as smoking or alcohol use is a must to improve
symptoms. Many people may have flare-up from time to time depending
on the many factors that affect the stomach lining. In general, gastritis is
mildly troubling ailment that responds well to simple treatment. Only
rarely can it become serious or even life-threatening.
1.16 PATHOPHYSIOLOGY
CASE STUDIES
1.17 REFERRENCES
i. Oxford Handbook of Clinical Medicine. 2014. Murray Longmore et.
al. (6) Gastroenterology. Pg.234. Ninth Edition. United States.
ii. Oxford Concise Medical Dictionary. 2010. Elizabeth. A et. al.
Gastritis. Pg.298. Eighth Edition. United States.
iii. Only My Health. 2016. Dr. Poonam Sachdev : Prognosis of
Gastritis. www.onlymyhealth.com. (30 August 2016)
iv. National for Rare Disease Organization : Gastritis, Chronic,
Erosive. rarediseases.org. (30 August 2016)

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JN/DIP.MED.

STUDENT NAME : JESICA NURIN ANAK GRAMAN

1.1 PATIENT PROFILE

1.3 HISTORY OF PRESENT ILLNESS

1.4 PAST HEALTH HISTORY

1.5 FAMILY HISTORY

1.6 SOCIAL HISTORY

1.7 HEALTH MAINTANENCE ACTIVITIES

1.8 PHYSICAL ASSESSMENT

1.10 DIFFERENTIAL DIAGNOSIS

1.12 MANAGEMENT AND TREATMENT

Gastritis is the inflammation of the lining (mucosa) of the stomach.

HISTORY OF PRESENT ILLNESS

1.4 PAST HEALTH HISTORY

Had heart disease

1.7 HEALTH MAINTANENCE ACTIVITIES

Special maneuvers : Bicep and triceps jerk : Both good

1.12 MANAGEMENT AND TREATMENT

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