The patient presents symptoms of diarrhea, nausea, and vomiting. The patient’s current drug prescription include daily 100 mg of Synthroid for the treatment of hypothyroidism, 30mg of Nifedipine for high blood pressure or any form of angina, and 10mg of prednisone for anti-inflammation or immune suppressant for multiple diseases. (Arcangelo & Peterson, 2017). The patient has also been linked with substance abuse and likelihood of Hepatitis C. A primary diagnosis, differential diagnosis, and drug therapy and treatment plan should be provided to the patient in order to assist them.
Primary Diagnosis
An intensive diagnosis of patient HL requires a comprehensive history and physical examination. However, a primary diagnosis can still be used. Considering the patient’s present symptoms; I would give a primary diagnosis of acute gastroenteritis. Acute gastroenteritis usually inflames and irritate the stomach and intestinal walls (Agawu, Wehrman, Pogoriler, Terry & Lin, 2019). Bacterial infection, viruses, parasitic infection, and toxic substances are known to cause irritation and inflammation of the stomach and intestinal walls. The presenting symptoms of acute gastroenteritis include nausea, vomiting, diarrhea, and clamping. One may contract the illness through eating contaminated foods and beverages or by skin contact with an infected person. The manifestations usually appear within 1-3 days after one takes contaminated foodstuffs (Agawu, Wehrman, Pogoriler, Terry & Lin, 2019). By considering disease manifestation signs (vomiting, nausea, and vomiting) with the absence of fever, I would recommend acute bacterial gastroenteritis.
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Differential Diagnosis.
Based on the patient’s history of drug abuse which could be intravenous (IV) drug use and the presenting symptoms, I would provide a differential diagnosis of acute hepatitis C flare-up. Hepatitis C causes liver inflammation caused by a Hepatitis C virus and is transmitted from one person to another through contact of bodily fluids, sexual intercourse, blood, and sharing of sharp objects as syringes for those who engage in substance use (Savytska, Solodovnichenko, Pavlenko, Shutova & Kaafarani 2019). The signs and symptoms include chronic abdominal pains and sometimes diarrhea. Diarrhea develops during acute hepatitis. The initial phase of infection may result in no manifestation with 20-30% of people experiencing the symptoms within the first three months of disease.
Drug Therapy and Treatment Plan
The primary goal of therapy is to minimize the symptoms and to prevent complications (Arcangelo & Peterson, 2017). Because the patient is experiencing nausea, vomiting, and diarrhea, I would start with intravenous fluid hydration either with 0.9% normal saline to replace the fluid lost from vomiting and diarrhea, and also prevent further dehydration (Arcangelo & Peterson, 2017). A complete blood count (CBC) with a differential diagnosis would be obtained to find out the type of bacteria and with CMP (Complete Metabolic Panel) to find out the electrolyte that needs to be replaced. If the results obtained indicate that potassium is low, I would change the fluid from 0.9 NS and add potassium to the intravenous fluid. I would also order Phenergan and Zofran to be given intravenous pyelogram as required for nausea and vomiting every 6 hours. Imodium is a first-line drug to treat diarrhea, and it can be purchased over-the-counter (Arcangelo & Peterson, 2017). Once nausea subsides, I will then advise patient HL to take water and adequate fluids such as broth to help replace fluids and electrolytes lost.
Additionally, the patient presents diarrhea, and therefore I would order a stool specimen examination to find out if the patient is having clostridium difficult (C-diff) or if the gastroenteritis is viral or bacterial (Zhou, Zuo, Tian, Wang, Ye, An, Li, 2016). If the results indicate viral, I would continue with IV fluid and encourage bowel rest by placing the patient on NPO (No food by mouth) for a day or two and depending on the ion severity; I would start the patient on Flagyl which is an anti-infective agent. However, if it is a bacterial infection, I would continue with IV fluid and an antibiotic like a broad-spectrum antibiotic such as Ciprofloxacin (Zhou et al. 2016). Also, I would do a complete thyroid panel test to adjust patient’s Synthroid, do a liver and hepatitis c test to start patient on treatment for hepatitis C, I would establish the reason the patient was on prednisone, the duration of drug use and to evaluate if the drug use can be reduced.
References
Agawu, A., Wehrman, A., Pogoriler, J., Terry, N. A., & Lin, H. C. (2019). A case report of a challenging diagnosis of biliary atresia in a patient receiving total parenteral nutrition. BMC Pediatrics , (1).
Arcangelo, V. P., & Peterson, A.M. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (3 rd . Ed.).
Savytska, I.G. Solodovnichenko, N.V. Pavlenko, O.V. Shutova, & A.M. Kaafarani. (2019). Functional disorders of the biliary tract in children: issues of diagnosis and correction from the position of the Rome IV criteria. Zdorovʹe Rebenka , (0), 64.
Zhou, Q., Zuo, M., Tian, Y., Wang, Y., Ye, Y., An, C. … Li, Q. (2016). Multi-centric clinical study of the effect of intervention time on efficacy of gastroparesis external application prescription treatment of gastrointestinal tumor postsurgical gastroparesis. Journal of Traditional Chinese Medical Sciences , 3 (4), 212–219.
