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 with her family. She has had nausea and one instance of vomiting before presentation.
PMH: Vitals:
HTN Temp: 98.8oF
Type II DM Wt: 202 lbs
Gout Ht: 5’8”
DVT – Caused by oral BCPs BP: 136/82
HR: 82 bpm
Current Medications: Notable Labs:
Lisinopril 10 mg daily WBC: 13,000/mm3
HCTZ 25 mg daily Total bilirubin: 0.8 mg/dL
Allopurinol 100 mg daily Direct bilirubin: 0.6 mg/dL
Multivitamin daily Alk Phos: 100 U/L
AST: 45 U/L
ALT: 30 U/L
Allergies:
Latex
Codeine
Amoxicillin
PE:
Eyes: EOMI
HENT: Normal
GI:bNondistended, minimal tenderness
Skin:bWarm and dry
Neuro: Alert and Oriented
Psych:bAppropriate mood
Review the case study assigned by your Instructor for this Assignment.
Reflect on the patient’s symptoms, medical history, and drugs currently prescribed.
Think about a possible diagnosis for the patient. Consider whether the patient has a disorder related to the gastrointestinal and hepatobiliary system or whether the symptoms are the result of a disorder from another system or other factors, such as pregnancy, drugs, or a psychological disorder.
Consider an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.
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