- 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.
- Please use the following case for this 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 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
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references
Expert Solution Preview
Introduction:
This case study presents a 46-year-old female patient, DC, who presents with RUQ pain and other symptoms. As a medical professional, it is essential to evaluate the patient’s symptoms, past medical history, current medications, and laboratory findings to make an accurate diagnosis and create an appropriate drug therapy plan.
1. Explain your diagnosis for the patient, including your rationale for the diagnosis.
Based on the patient’s symptoms, history, and laboratory findings, my primary diagnosis for DC is acute cholecystitis. The RUQ pain, nausea, and vomiting occurring after a large meal, which is a common trigger for cholecystitis, along with an elevated WBC count suggests acute inflammation of the gallbladder. The patient’s elevated bilirubin levels and alkaline phosphatase indicate possible obstruction of the bile duct.
2. Describe an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.
The appropriate drug therapy plan for DC includes pain management, antiemetic therapy, and antibiotics. Pain management medication such as acetaminophen or ibuprofen can be administered to manage the patient’s RUQ pain. Antiemetic therapy such as promethazine or ondansetron can be given to control the patient’s nausea and prevent further episodes of vomiting. Antibiotics such as ciprofloxacin or levofloxacin along with metronidazole can be prescribed to treat the acute cholecystitis.
3. Justify why you would recommend this drug therapy plan for this patient. Be specific and provide examples.
I would recommend this drug therapy plan for DC as it addresses the patient’s symptoms while also addressing the underlying condition of acute cholecystitis. Pain management medication and antiemetic therapy can provide symptomatic relief while the prescribed antibiotics can help to treat and clear the infection causing inflammation of the gallbladder. Additionally, the choice of antibiotics is appropriate for the patient, taking into consideration any possible allergy history, as well as the patient’s current medications. The bacterial coverage of the chosen antibiotics is also appropriate for the suspected infection. This drug therapy plan is evidence-based and clinically effective in treating acute cholecystitis.
