Health & Medical Pain Health Developing a Treatment Plan Case Study


Case study:

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You are working in an emergency department and your patient is John D, a 72-year-old male. Patient lives at home with his wife. She is at home and unable to perform all her ADLs and he takes care of her along with a home aide. John D presents with a complaint of frequent (4-5 per day) loose stools for the last two days. He has normally 1 bowel movement/day and they are formed. He denies any recent travel out of the country or any blood in the stool. He has mild indigestion but no other abdominal pain or discomfort. He denies history of the same. He exercises daily with senior friends in the community. He eats healthy and denies any changes in diet. Patient denies any trauma. Focused abdominal exam is unremarkable. He has been self treating with blackberry root, which helped somewhat.  He has a recent history of prostatitis and is being treated for this. He has a past history of hypertension, rheumatoid arthritis, hyperlipidemia. He has not had any major surgeries. No recent exposure around anyone with the same symptoms.

Vitals: Temp-36.3, Pulse-92, RR-16 BP-101/59 O2-100%

Metoprolol XR 25mg PO Daily

Lisinopril / HCTZ 10/12.5mg PO Daily

Simvastatin 20mg PO Daily

Ibuprofen 200mg PO TID

Ciprofloxacin 500mg PO BID

Write what your diagnosis, admission decision, and treatment plan are. Be as detailed as possible and provide “medical decision making”. This is your justification and will be required as a provider to support all your decisions. Your plan must be supported by an evidence-based source such as CPGs.

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