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Clinical Case Study – Learning Points

In order to provide a diagnosis it is important to understand Patient’s history and current status.
The current and past symptoms together help determine the test required and medications to be prescribed.
An effective diagnosis takes into consideration the past treatments of the patient.
Patients need to be educated about their medications and timely intake.
Vision for Patient Education Care Plan
It was observed in this case that the patient was wary of medications. As part of the care plan, it must be ensured that the patient is comfortable with medications.

Patient must be educated on the importance of taking medications regularly and timely and getting prescribed tests done.

All alternative therapies and medications being taken by the patient must also be analyzed in order to foresee any plausible side-effects.

Key Points of Patient’s Current Diagnosis

HPI indicates acute abdominal pain and patient is feeling feverish and nauseous.
Symptoms are intermittent heartburn, but cardiovascular activity is normal.
Physical examination shows normal blood count, liver and pancreas.
The patient has gastrointestinal infection or ulcer that is a result of excessive intake of NSAIDs which the patient was taking for last a month to treat gout.

Painkillers (NSAIDs) caused disturbance to bile resulting in heartburn (Singh & Triadafilopoulos, 1999).

Tests Ordered for Current Diagnosis
According to the previous symptoms, family history and medication taken by the patient following diagnostic tests are prescribed:
Abdominal radiology to analyse inflammation in any quadrants (abdomen and liver).
Amylase & Lipase tests to check acute or chronic pancreatitis.
CBC and LFT tests to examine liver functioning and other infections.
EKG test to analyse heart rhythm because of increased systolic pressure (Ecglibrary.com.).
Based on the symptoms physical examination and blood tests, and H. pylori positive test confirms the condition of gastrointestinal ulcer (Graham. 1991).

Patient Education for Gastrointestinal System

Patient should be told about the effects and long term impacts of GI infections.
Patient should be educated to change his eating and drinking habits (Nlm.nih.gov).
Patient should be made aware of adverse effects of psychological depression that can intensify the GI symptoms (Med.unc.edu).

REFERENCES

Ecglibrary.com,. (2015). ECGlibrary.com: Normal adult 12-lead ECG. Retrieved 14 February
2015, from http://www.ecglibrary.com/norm.php
Graham, D. Y., Malaty, H. M., Evans, D. G., Evans, D. J., Klein, P. D., & Adam, E. (1991).
Epidemiology of Helicobacter pylori in an asymptomatic population in the United States.
Gastroenterology, 100(1495), 501.
Med.unc.edu,. (2015). What are FGIDs? — UNC Center for Functional GI & Motility Disorders
- UNC School of Medicine. Retrieved 14 February 2015, from
http://www.med.unc.edu/ibs/patient-education/what-are-fgimds
Nlm.nih.gov,. (2015). Stomach Disorders: MedlinePlus. Retrieved 14 February 2015, from
http://www.nlm.nih.gov/medlineplus/stomachdisorders.html
Singh, G., & Triadafilopoulos, G. (1999). Epidemiology of NSAID induced gastrointestinal complications. The Journal of rheumatology. Supplement, 56, 18-24.