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Clinical Assessment of a Patient’s Medical History and Presenting Symptoms

This paper examines a case of patient HL with symptoms like vomiting, nausea, and diarrhoea. HL has a past of possible Hepatitis C and drug abuse and is currently taking Synthroid 100 mcg, Nifedipine 30 mg, and Prednisone 10 mg daily.

Summary

From the HL medical history and presenting symptoms, HL’s condition is associated with gastrointestinal and the most probable diagnosis is gastritis. Gastritis refers to a condition wherein the lining of the stomach, the mucosa, is swollen or inflamed (Massironi et al., 2019). When a person’s stomach lining is swollen or inflamed, fewer enzymes and less acid are produced (Minalyan et al., 2017). The stomach lining during this state also produces less mucus as well as other substances that usually safeguard the lining of the stomach from acidic digestive juice (Koskenpato et al., 2002). There are two kinds of gastritis: non-erosive and erosive. Erosive gastritis has the ability of causing wearing away of the stomach lining, thus causing erosions or ulcers in the lining of the stomach (Siurala et al., 2009). Conversely, non-erosive gastritis is whereby the lining of the stomach is not worn away, yet it can degenerate (Massironi et al., 2019). When gastritis occurs suddenly, the same is referred to as acute gastritis and when it occurs over a protracted span of time, it is referred to as chronic gastritis (Massironi et al., 2019).

Some causes of reactive gastritis include Nonsteroidal anti-inflammatory drugs (NSAIDs) (like ibuprofen and aspirin), drinking of alcohol, exposure to radiation, using cocaine, reflux of bile from one’s small intestine into the stomach, and a response to stress caused by critical illnesses, traumatic injuries, major surgery, and severe burns (Koskenpato et al., 2002). Of these causes, it is highly possible that drug abuse is the cause for gastritis in HL. Similarly, HL’s presenting symptoms could also be associated with what HL is experiencing. Some of the symptoms associated with gastritis include continuous pain in one’s epigastric region that is often accompanied by vomiting, diarrhoea, nausea, or fever (Minalyan et al., 2017)).

Based on the patient’s diagnosis, drugs, and history, the most appropriate therapy is to avoid foods that are likely to compound the problem, like spicy, fatty, or (very) acidic food items (like orange juice, coffee, and tomato juice) (Siurala et al., 2009). The patient should also avoid medications like NSAIDs and avoid excessive alcohol intake (Koskenpato et al., 2002). Medication treatment options for HL would include taking acid reducing drugs, like proton pump inhibitor, H2 blocker, and antacid (Minalyan et al., 2017). I would strongly recommend antacids to the patient since they do not cause side effects such as diarrhoea because HL is already suffering from diarrhoea. To remedy HL’s vomiting and nausea, Phenergan 12.5 mg or Compazine 5mg for every 4-6hrs could do (Massironi et al., 2019).