Subjective Data
Chief Complaint: Mrs. T is a 67-year old lady who presents at the clinic with complaints of indigestion and abdominal pains. She describes the pain as dull and constant that emanates from the upper right quadrant of the abdomen. The pain, she says began three days ago, and has been progressing significantly such that the last two evenings she has not been able to sleep at all. At times, she says the pain extends to the right arm and shoulder and that she has been vomiting and has had severe nausea especially after meals. She feels excess gas and significant bloating while rating her pain at 7.
Past Medical History: she has not significant medical history and she rarely goes to hospital.
Past Surgical History: caesarian section …show more content…
Medical Diagnosis Gall stone disease: The family history with gall stone disease is a major justification for this diagnosis. However, the presenting symptoms all point to the same illness (Warttig, Ward, & Rogers, 2014). Gastritis: The abdominal pain, nausea and vomiting are all symptoms associated with gastritis but this usually occurs when the patient feels distributed pain across the entire abdomen. Peptic ulcer disease: Bloating and excess gas as well as vomiting and nausea are symptoms synonymous with peptic ulcer disease. However, the patient does not complain of heart burn which is the most unique symptom for peptic ulcers (Warttig, Ward, & Rogers, 2014).
Pathophysiology: Gall stone disease are hard, pebble-like structures that obstruct the cystic duct. Gastritis can be caused by stress the patient experience running her business left by her disease husband. Peptic Ulcer Disease is more sensitive to the ulcer causing effects of NSAIDs especially in elderly.
Consultation/Collaboration:
No referrals were made in this case. The case could be possible referred to a Gastroenterologist because the medical diagnosis listed above.
Pharmacology
Chief Complaint: Mrs. T is a 67-year old lady who presents at the clinic with complaints of indigestion and abdominal pains. She describes the pain as dull and constant that emanates from the upper right quadrant of the abdomen. The pain, she says began three days ago, and has been progressing significantly such that the last two evenings she has not been able to sleep at all. At times, she says the pain extends to the right arm and shoulder and that she has been vomiting and has had severe nausea especially after meals. She feels excess gas and significant bloating while rating her pain at 7.
Past Medical History: she has not significant medical history and she rarely goes to hospital.
Past Surgical History: caesarian section …show more content…
Medical Diagnosis Gall stone disease: The family history with gall stone disease is a major justification for this diagnosis. However, the presenting symptoms all point to the same illness (Warttig, Ward, & Rogers, 2014). Gastritis: The abdominal pain, nausea and vomiting are all symptoms associated with gastritis but this usually occurs when the patient feels distributed pain across the entire abdomen. Peptic ulcer disease: Bloating and excess gas as well as vomiting and nausea are symptoms synonymous with peptic ulcer disease. However, the patient does not complain of heart burn which is the most unique symptom for peptic ulcers (Warttig, Ward, & Rogers, 2014).
Pathophysiology: Gall stone disease are hard, pebble-like structures that obstruct the cystic duct. Gastritis can be caused by stress the patient experience running her business left by her disease husband. Peptic Ulcer Disease is more sensitive to the ulcer causing effects of NSAIDs especially in elderly.
Consultation/Collaboration:
No referrals were made in this case. The case could be possible referred to a Gastroenterologist because the medical diagnosis listed above.
Pharmacology