Burning Sensation in Stomach Walls: Patient History - Case Study

“I have a burning sensation in my stomach walls that are sharp and painful. The pain occasionally comes after having the main meal”.

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Patient History.

Before this visit, N.L agrees that he has had occurrences in the past that caused him to feel a similar pain. In previous years, she has reported suffering from stomach ulcers that were treated and were assumed to be healed. However, since it was assumed to be healed, she did not purchase more medication after the dose was complete. Recently, she reports that she has had the pain surge through her stomach more than twice. On those occasions, she assumed that it was just a mild stomach infection and purchased painkillers. However, a week later, the pain kept coming through and became consistent. She also says that she has had occasional hurt buns. She reports that she has used milk to surge the hurt buns, but they keep coming through. The stomach walls keep burning and are painful, indicating that there is high hydrochloric acid that is rapidly digesting the walls for lack of food bacterial, causing an ulcer.

Current medications:

The patient is currently on proton pump inhibitors (PPIs). The role of the PPIs is to block the further secretion of hydrochloric acid from the stomach cells. The specific PPIs that N.L is consuming are Prevacid and Protonix. She consumes 500 mg tablets of Prevacid once a day and 200 mg tablets of Protonix twice a day. It also seeks to reduce the level of acid that already exists in the stomach. N.L is also on penicillin and antibiotic medication for the various complaints made initially.

Allergies:

N.L is allergic to aspirin medication and warfarin.

Patient Medical History

The patient has a history with mild stomach ulcers that were treated with Prevacid and Protonix. The patient has also resorted to milk to reduce the occasional burns.

Family Medical History:

The patient reports that her father had a very serious peptic ulcer. Thus, it may be assumed that the patient’s current situation has some genetic relation. There is some tangible evidence to ascertain that an ulcer can be inherited. The pattern followed by this genetic transition is dependent on a variety of actors and thus not simple. For instance, peptic ulcers have supporting risk factors like smoking of cigars.

Social History

N.L admits that she consumes alcohol at least four times a week. She has an experience with alcohol addiction that she says landed her in a rehabilitation centered. Even years later, she has not fully recovered from the addiction. Alcohol has a high acidity level that burns the stomach was making them prone to an ulcer. There is a proven relationship between the H. Pylori bacteria and the alcohol consumption that leads to stomach ulcers and other disorders like gastritis.

Review of Systems

Physical Observations

Mrs. N.L is very active, has her eyesight in check, and is very attentive despite the pain cruising through her stomach. She complains about the pain at least seven times during the diagnosis (Nature.com, 2020). She had breakfast in the morning and occasionally drinks milk from her bottle even though she reports bloating in the stomach. Mrs. N.L also looks fatigued even though she denies it.

HEENT:

The patient has no reports of headache; neither are the eyes affected. The eras are also in check. However, she keeps on feeling throbbing nausea and has vomited twice since she entered the office. There is no sneezing or nose disorder so far.

Skin:

The patient reports that there is no rash on her skin, which is warm and has no sign of a fever.

Cardiovascular:

Mrs. N.L reports frequent heartburns that are painful through the chest area. There are no palpitations or edema, as the patient denies.

Respiratory:

The patient denies any respiratory or breathing problems.

Gastrointestinal:

On a scale of 1-10, the patient rates the abdominal pain as 7. There is a change in bowel movements as the patient feels a burning sensation. She also has vomited twice since entering the office and still feels nausea.

Neurological:

The brain area is so far, not affected since there is no headache or signs of stress. There are no colon disruptions in the abdomen.

Genitourinary:

There is no dysuria or hematuria.

Musculoskeletal:

There is no back pain, but she feels pain in the external muscles of the stomach.

Lymphatic:

The patient denies splenectomy disorder.

Psychiatric:

The patient negates depression as a result of the pain.

Differential Diagnosis

Stomach Cancer: The patient us seemingly suffering from cancer. Stomach cancer is a result of gene mutation in the DNA that is a result of gastrointestinal reflux disease (GERD). The patient is quite obese and has smoked once a while, which are the common risk factors for the disease. GERD result from the backflow of hydrochloric acid from the stomach to the esophagus. Common risk factors other than smoking is the consumption of smoked foods and salted ones (Nature.com, 2020). However, the emergence of refrigerators is gradually causing a reduction in stomach cancer cases.

Teaching Recommendations

The recommended teaching is focused on reducing the acid level in the stomach and mitigating reflux (Mayo Clinic, 2020). The patient should learn to exercise frequently. One also has to reduce the salt content in their foods and avoid smoked foods. Thus, the main teaching recommendations are on nutrition, exercising, and appropriate medication. High consumption of junk foods should be reduced as the patient avoids smoking.

Reflection

I must admit that gastrointestinal assessment is rigorous yet educative. I got the chance to understand the entire process. It never crossed my mind that the conditions like ulcers stomach cancer can be genetic. However, the assessment gave such insight. My patient was very cooperative and willingly shared information. I hope that my future clients will give such an easy time. The knowledge acquired will help me to increase my understanding when dealing with such patients.

References

Mayo Clinic. (2020). Stomach Cancer. https://www.mayoclinic.org/diseases-conditions/stomach-cancer/symptoms-causes/syc-20352438
Nature.com. (2020). Stomach Diseases. https://www.nature.com/subjects/stomach-diseases#:~:text=Stomach%20diseases%20include%20stomach%20cancer,bloating%2C%20diarrhoea%20and%20abdominal%20pain.