SCNARIO: CJ, a 35 year-old female, presents to the urgent care clinic due abdominal pain. For the past 2 weeks, she was experiencing abdominal pain that make her woke up at night, but it is relieved by food and antacids. She was diagnosed with Grave’s disease 3 months ago with symptoms of hyperthyroidism and tachycardia. She also has chronic renal dysfunction due to polycystic kidney disease. Moreover, she has IBS with complaints of diarrhea and constipation, with increasing episode over past 2 months. She was also diagnosed with iron deficiency anemia. CJ was married and had 2 children. She smoke ½ pack per day and drinks 2 glasses of wine per day with dinner and coffee 2-6 cups per day.
SCNARIO: CJ, a 35 year-old female, presents to the urgent care clinic due abdominal pain. For the past 2 weeks, she was experiencing abdominal pain that make her woke up at night, but it is relieved by food and antacids.
She was diagnosed with Grave’s disease 3 months ago with symptoms of hyperthyroidism and tachycardia. She also has chronic renal dysfunction due to polycystic kidney disease. Moreover, she has IBS with complaints of diarrhea and constipation, with increasing episode over past 2 months. She was also diagnosed with iron deficiency anemia.
CJ was married and had 2 children. She smoke ½ pack per day and drinks 2 glasses of wine per day with dinner and coffee 2-6 cups per day.
Medication:
PTU 200 mg PO q6h
Magnesium hydroxide/Al hydroxide Susp 15mL PO PRN
Propranolol 20 mg PO qid.
Allergies: NKA
Physical Examination:
Gen: Well developed, thin female in mild distress
VS: BP 140/88, HR 84, RR 18, T 37oC. Wt 55 kg, Ht 165cm
HEENT: Small symmetric goiter, much smaller than previous clinic visit
Coronary: Normal S1 and S2, no murmurs, rubs, or gallops
Chest: WNL
Abdomen: Intermittent, crampy, lower abdominal pain relieved by passage of flatus; point tenderness between the xiphoid and umbilicus
Genitourinary: WNL
Ext: Pruritic pretibial myxedema
Neuro: WNL
Laboratory Examination Results: (SI UNIT)
|
Na |
128 mmol/L |
Fe |
9.8 umol/L |
Plts |
120 x 109/L |
|
K |
4.8 mmol/L |
Mg |
1.35 mmol/L |
Glu |
4.7 mmol/L |
|
Cl |
102 mmol/L |
MCV |
68 um3 |
Ca |
2.1 mmol/L |
|
HCO3 |
20 mmol/L |
AST |
0.42 ukat/L |
Uric Acid |
535 umol/L |
|
BUN |
28.6 mmol/L |
ALT |
0.45 ukat/L |
T Bili |
15.4 umol/L |
|
Cr |
283 (3.2) |
PO4 |
1.6 mmol/L |
TT4 |
100 nmol/L |
|
Hct |
0.29 |
Alb |
35 g/L |
RT3U |
0.3 nmol/L |
|
Hgb |
100 mmol/L |
LDH |
1.1 ukat/L |
FT4I |
34 pmol/L |
|
LKcs |
5 x 109 cells/L |
Alk Phos |
1.1 ukat/L |
TSH |
5 mIU/L |
Stool guaiac test: Guaiac-positive stool
¹1Differential test: WNL
Urinalysis: Hematuria, proteinuria
Chest radiography: WNL
ECG: WNL
Endoscopy: Two small duodenal ulcers
Peripheral blood smear: Microcytic anemia
PLANNING: This section is where the final treatment plan is given for each of the active problems as justified in the assessment.
|
Health care problem |
Therapeutic Goals |
Recommendation (Drug or Non-drug) |
Monitoring Parameters (frequency of monitoring) |
Endpoints |
Step by step
Solved in 3 steps
