Week 4 Case Assignment 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 on instance of vomiting before the presentation. PMH: Vitals: HTN Temp: 98.8oF Type II DM Wt: 202 lbs Gout Ht: 5’8”

Gastrointestinal and Hepatobiliary Disorders

Case study

The patient is a 46-year-old female who reports to the facility complaining of right upper quadrant pain that has occurred for the past 24 hours. She highlights that the pain began one hour after she had dinner. She experienced nausea and vomiting before the pain started. The patient has a history of gout, deep vein thrombosis, hypertension, and type 2 diabetes. Her daily current medications include allopurinol 100 mg , Lisinopril 10mg, multivitamin and hydrochlorothiazide 25mg. The patient’s vital readings show a blood pressure of 136/82mmHg, heart rate of 82 bpm, temperature of 98.8F, height of 5’8″, and weight of 202 lbs. Her laboratory tests show WBC of 13,000/mm3, Total bilirubin of 0.8 mg/Dl, Direct bilirubin of 0.6 mg/Dl,             ALT of 30 U/L, AST of 45 U/L and alkaline phosphatase of 100 U/L. She is allergic to codeine, latex, and amoxicillin. Her physical examination shows a non-distended abdomen with minimal tenderness.

Diagnosis and Rationale                                    

The diagnosis is food poisoning. The patient began experiencing nausea, vomiting, and right upper quadrant pain one hour after eating. Patients diagnosed with food poisoning have varying degrees and combinations of signs and symptoms, including abdominal pain, vomiting, nausea, diarrhea, fever, headache, bloating, and stool changes. The patient experienced nausea, vomiting, and diarrhea from the above symptoms. The patient is allergic to amoxicillin, codeine, and latex. She has no known food allergy; therefore, her food could not have led to an allergic reaction.

Drug Therapy Plan and Rationale                                     

Although the patient had only one episode of vomiting, it is crucial to evaluate for any signs of dehydration. Fluids and electrolytes are lost during vomiting (Taylor & Jones, 2022). In case of dehydration, there is a need for electrolyte supplementation and rehydration. An oral rehydration solution is prescribed. The patient is encouraged to have an adequate intake of fluids. There is a need for pain management since the patient is complaining of right upper quadrant pain. The medication was administered on the pain scale. Painkillers such as paracetamol 1g thrice a day for three days can be prescribed to manage mild to moderate pain (Queremel et al., 2022). the patient has been in pain for the past 24 hours; therefore, there is no adequate reason for stool cultures. Stool cultures are recommended when a patient has experienced signs and symptoms for three to four days. Empirical treatment is initiated. The patient has been prescribed ciprofloxacin 500mg, taken once daily for five days. The patient has a known allergy to amoxicillin; therefore, she could be allergic to all penicillins. Ciprofloxacin is a fluoroquinolone that can substitute for penicillin allergy (Thai et al., 2022).

                  References

Queremel Milani DA, Davis DD. (2022). Pain Management Medications. StatPearls Publishing https://www.ncbi.nlm.nih.gov/books/NBK560692/.

Taylor K, Jones EB. (2022). Adult Dehydration. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK555956/.