Case Study 4 - Patient who presents with symptoms of a possible GI

Case Study 4

To prepare:

Please review the case study below, evaluate and determine a diagnosis for the case study patient who presents with symptoms of a possible GI/hepatobiliary disorder. You will then justify your diagnosis, including your rationale for the diagnosis. Based upon your diagnosis, you will then determine an appropriate treatment plan for the case patient. Please ensure that you provide the appropriate dose, route and frequency of administration of the medication(s) prescribed. Approach this as if you are writing a prescription for your patient - what drug, dose, route and frequency would you prescribe?

DC is a 46-year-old female who presents with a 24-hour history of RUQ pain. She states the pain started about 1 hour after a large dinner she had with her family. She has had nausea and one instance of vomiting before presentation.

PMH:

HTN

Type II DM

Gout

DVT – Caused by oral BCPs

Vitals:

Temp: 98.8°F

Wt: 202 lbs

Ht: 5’8”

BP: 136/82

HR: 82 bpm

Current Medications:

Lisinopril 10 mg daily

HCTZ 25 mg daily

Allopurinol 100 mg daily

Multivitamin daily

Notable Labs:

WBC: 13,000/mm3

Total bilirubin: 0.8 mg/dL

Direct bilirubin: 0.6 mg/dL

Alk Phos: 100 U/L

AST: 45 U/L

ALT: 30 U/L

Allergies:

Latex

Codeine

Amoxicillin

PE:

Eyes: EOMI

HENT: Normal

GI: Nondistended, minimal tenderness

Skin: Warm and dry

Neuro: Alert and Oriented

Psych: Appropriate mood

Question

Write a 2 page paper that addresses the following:

Explain your diagnosis for the patient, including your rationale for the diagnosis.

Describe an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.

Justify why you would recommend this drug therapy plan for this patient. Be specific and provide examples.