The patient presents with anorexia, heartburn, and weight loss over the past 6 months while also complaining of back pain. All these symptoms point to a problem within the gastrointestinal system which is slowly developing and which if not managed at this early stage could progress to severity. The weight loss over the last six months is an indication of the inability of the body to process and utilize the meals taken as would be expected and the body is currently more reliant on the food/energy reserves (Jarvis, 2015).
In this case, there are three possible causes for these symptoms; on one hand, the patient could be having acute gastritis. It is characterized by vomiting and nausea, fever, abdominal pains as well as headache and instances of heart burn. However, the fact that this condition has a unique condition in which the patient may vomit blood or have stool with blood stains would definitely rule this condition (Roberts, 2012). However, in its initial stages, the condition presents with a majority of the symptoms presented by the patient in this case study.
On the other hand, this condition could potentially be GERD which is also characterized by heart burn, acid reflux, nausea and vomiting and subsequent weight loss (Konturek, Brzozowski & Konturek, 2011). However, this condition is uniquely characterized by chest pain and a dry cough. In the case of this patient, GERD is ruled out on the basis that the patient reports pain as emanating from the back as well as the fact that there are no sore throat complaints.
For this patient, the condition can be diagnosed as stomach ulcers. Normally, stomach ulcers is characterized by dull pain within the stomach, weight loss, nausea and vomiting, bloating, heart burn and pain is relieved on food consumption or use of an antacid as is the case with this patient (Roberts, 2012). In most cases, the dull pain in the stomach will be felt as a sharp pain that emanates from the back as it is the case with this patient. This pain too subsides or goes away on the use of antacids and it is usually short-lived. The patient’s smoking history also gives further credence to the possibility of a stomach ulcer since smoking is a significant influencing factor for this condition (Konturek, Brzozowski & Konturek, 2011).
The role of patient history and physical examination
A majority of gastrointestinal disorders have related symptoms and it is important that the healthcare provider develops a comprehensive history and analysis of the patient to come up with the correct diagnosis. In the case of this patient, the lacking elements of family history would have been influential in making a more accurate diagnosis but more importantly in developing a tailored care plan (Jarvis, 2015). The physical examination is equally crucial as it has helped eliminate the GERD for instance on the basis that the pain complaint from the patient is felt from the back and not from the chest. These small details can only be available when the patient’s history and physical examination is exhaustively done (Jarvis, 2015).
Treatment
The patient will be subjected on H2 blockers such as Zantac 300 mg to help limit the amount of acid that the stomach produces. This will significantly reduce the pain but it is a short term solution to help stabilize the self regulation of stomach acid. The patient will also be provided with pepto-bismol medication which is a cyto-protective agent that plays the role of protecting the stomach and small intestines linings. The patient will also be required to quit alcohol use or any other tobacco products to avoid straining an already weakened system. The patient has to avoid stress or seek methods for managing stress in a more amicable way such as light physical exercise (Konturek, Brzozowski & Konturek, 2011).
References
Jarvis, C. (2015). Physical examination & health assessment (7th ed.). St. Louis, MO: Saunders Elsevier.
Konturek, P. C., Brzozowski, T., & Konturek, S. J. (2011). Stress and the gut: pathophysiology, clinical consequences, diagnostic approach and treatment options. J Physiol Pharmacol, 62(6), 591-599.
Roberts, J. E. (2012). Abdominal migraine, another cause of abdominal pain in adults. The American journal of medicine, 125(11), 1135-1139.
