The Pertinent Positives and Negatives on Examination related to his Presenting Problem
A pertinent positive is a symptom or sign that contributes to the identification of a patient’s medical problem. Pertinent negative refers to the absence of a symptom that can help in substantiating the medical condition from which a patient could be suffering. Pertinent positives and negatives are usually captured during the physical examination and after taking the medical history of a patient. The pertinent positives and negatives contribute towards the differential diagnosis of a patient.
In the case study given, the pertinent positives include; Dyspnea, hematemesis, dark stool, epigastric pains, dyspepsia, duodenal ulcer, moderate epigastric tendering, and stool guaiac. On the other hand, the pertinent negatives include; chest pain, orthopnea, edema, cough, wheezing, infections, cardiac or pulmonary diseases, allergies, spider angiomata on skin, auscultation in lungs, gallops, heaves, or thrills in heart rhythm, joint deformity, and muscle tenderness. The patient was also on “3 drugs at once” after he was diagnosed with duodenal ulcers, but stopped taking the medications two years ago.
Differential Diagnosis
Various conditions present themselves through similar symptoms, and therefore, establishing the exact disease producing the symptoms is important in making a diagnosis, as well as in treating the condition. A differential diagnosis is the process through which one weighs the possibility of one disease over that of another. A differentia diagnosis can be made based on the pertinent positives and negatives, and it helps in arriving at the right diagnosis.
In the case study given, the patient experiences dyspepsia, which refers to indigestion, and is characterized by heartburn, belching, fullness of the upper abdomen, and burning sensation (Ford & Tally, 2014). It could be a sign of GERD, hiatal hernia, anxiety and depression, duodenal ulcers, or side effects of over-consumption of alcohol, and in some cases, stomach cancer. The most probable cause for dyspepsia in this case is the duodenal ulcer, since the patient had been diagnosed with ulcers, but never completed the medications. Moreover, the patient is a heavy drinker, which could be facilitating dyspepsia. Therefore, the differential diagnosis for dyspepsia could be duodenal ulcers or the over-consumption of alcohol.
Stomach ulcer is the collective name used to describe gastric and duodenal ulcers. Gastric or peptic ulcers affect the oesophageal while the duodenal ulcers affect the small intestines (McColl, 2012). Stomach ulcers are characterized by a burning sensation in the tummy, dyspepsia, excessive belching, and sometimes vomiting blood. Also, passing dark stools is a sign of stomach ulcers. The patient in the case study has experienced hematemesis, especially after heavy drinking, and has also observed several days of passing dark stools. Hence, he could be having a duodenal ulcer.
Inflammatory Bowel Diseases, IBD, is a term used to describe the two most common inflammations of the digestive system. Crohn’s disease and ulcerative colitis are long-term diseases of the gastrointestinal tract, and they mostly exhibit the same symptoms (Nagalingam & Lynch, 2012). Therefore, to make a diagnosis, tests are done on the patient. Some of the common symptoms include extreme tiredness, weight loss, tummy pains, and bloody stool. The patient in the case study reported experiencing tiredness, dyspepsia, and dark stool. This indicates that he could be suffering from one of the IBDs because of the symptoms experienced.
At this point, laboratory studies should be done to establish the exact cause of the symptoms that the patient is experiencing. Some of the lab tests that should be done include gastroscopy, H. pylori test via urea test, blood test, or stool test, colonoscopy, endoscopy, computerized tomography enterograpy, and magnetic resonance enterography, CBC, and Small Bowel Enema, SBE.
Diagnosis based on the Laboratory results
The diagnosis for the patient based on the lab results is iron-deficiency anemia. According to Macdougall (2013), anemia is the deficiency of the red blood cells in the blood, which results to weariness, breathlessness, and tiredness. Mainly caused by a lack of iron in the body, anemia can also be caused by other underlying medical conditions. Anemia can emanate from lack of manufacture of enough red blood cells in the body, or by the excessive loss of the red blood cells, usually through bleeding.
In the case study, the patient admits to experiencing Dyspnea or breathlessness, which is the reason he came in to the hospital. The patient has also experienced hematemesis after episodes of drinking, as well as dark stools. Also, he has been diagnosed with duodenal ulcer in the past, although he didn’t complete the medication for its treatment. The lab results from the upper endoscopy indicate recent, although not acute hemorrhage of the ulcer, and this could be the reason behind the loss of the red blood cells.
Management of the Patient
Iron-deficiency anemia is caused by the lack of enough iron in the body. It can also be caused by digestive conditions such as inflammatory bowel diseases or the removal of any part of the stomach (Leontiadis & Sharma, 2012). Since it is iron-deficiency, the best management method is ensuring that the patient takes meals enriched with iron-rich foods. Also, if the underlying cause is a medical condition such as a hemorrhaging duodenal ulcer, the ulcer should be treated.
References
Ford, A. C., & Talley, N. J. (2014). Epidemiology of Dyspepsia. GI Epidemiology: Diseases
and Clinical Methodology, Second Edition, 158-171.
Leontiadis, G. I., & Sharma, V. K. (2012). Hematemesis, Melena, and Occult
Bleeding/Anemia. Problem-based Approach to Gastroenterology and Hepatology, 64.
Macdougall, I. C. (2013). Excluding Other Causes of Anemia. In Pocket Reference to Renal
Anemia (pp. 15-19). Springer Healthcare Ltd..
McColl, K. E. (2012). Pathophysiology of Duodenal Ulcer Disease. European Journal of
Gastroenterology & Hepatology, 9, S9-S12.
Nagalingam, N. A., & Lynch, S. V. (2012). Role of the Microbiota in Inflammatory Bowel
Diseases. Inflammatory Bowel Diseases, 18(5), 968-984.
