Patient Care Plan: Read the case and fill out the worksheet
RA is a 42 year old female (DOB: 2/1/1976) who comes to your pharmacy to ask you for a recommendation for her stomach troubles. She says she has been really busy with work lately and picked up a bottle of Tums recently from the store after seeing a commercial for it. She tried taking it once, saying “it seemed to work a little, but has not completely resolved my heartburn. There are so many other products I saw on the shelf, how do I know which one is best? Can you help me pick the right one?”
HPI:RA states that she tends to eat more when under stress. Due to lack of time, she admits to eating fast-food for every meal for the past month. She sometimes even ordered an extra entree on top of a standard meal “on especially bad days.” She likes to drink orange juice with meals lately because she thinks it helps “digest food better”. However, for the past couple of weeks, she has been unable to finish her meals sometimes because she feels “really full” after just a few bites of her burgers. Usually, when this happens, it is accompanied with stomach pain and a burning sensation in her lower chest. She embarrassingly admits that she also feels the need to “burp a lot” and has to stop eating.She describes this as a nuisance, and finds it especially inconvenient if it happens to occur at work when she is around her co-workers. She also indicates that the burning sensation reduces her concentration at work, which is bothersome but still tolerable at this time. The discomfort is rated a 6 on a scale of 110. She states that it “seems to happen once a week.” The last time she had an episode was earlier this week. This time the burning sensation got worse after she started drinking her orange juice. She took Tums which seemed to relieve her stomach pain, burning sensation and burping, but effect wears out fast. Denies sweating, SOB, weight loss or pain radiating to shoulder, arm, neck or jaw.
PMH:Seasonal allergic rhinitis, Osteoarthritis, Hypertension
FH:Hypertension (Father)
SH:Single, no children. Occupation: Lawyer
Alcohol use: 1 glass of wine 1-2 nights per week; Patient denies illicit drug use.
Since beginning of last year, she started to smoke again after quitting 2 years ago, usually 1/2 ppd but more when she feels really stressed out.
MED:Flonase® 50mcg/spray 1 spray each nostril BID
Tylenol® Extra strength – 1000mg PO Q6hrs PRN joint pain
Lisinopril/HCTZ – 20mg/12.5mg PO daily
Tums® – 2 chewable tablets PO as symptoms occur
Vaccines:All routine childhood/adult vaccination up-to-date
Last flu shot- September 2015
Allergies: NKDA
PEGEN:Overweight female, slightly distressed in appearance
Vital Signs:BP 130/79, HR 78, RR 17, T (temporal) 98.2F
Wt 70 kg, Ht 51
LAB:Within normal limit
Instructions: Work up this patient using the QuEST-SCHOLAR form and submit an electronic copy on Blackboard. Assignments submitted via email, after the deadline, or in an unconventional format will NOT be accepted. PAGE LIMIT = 2 pages.
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