MAKE A CASE STUDY. STRICTLY FOLLOW THE FORMAT BELOW.
Template for Case Study Format
Medical History
Chief Complaint or health problem
Present Medical History
Past Medical History
Problems
-List some specific problems regarding the case.
Possible Evaluation / Outcomes
CASE:
Complaint: upper abdominal pain and black stools over the last 2days.
Medical Diagnosis: Peptic Ulcer
History of Present Illness
An epigastric burning sensation present for the last 2 days
Her pain is moderately severe but non radiating – relieved alittle by
eating and by an antacid (Gaviscon)
No history of weight loss but some vomiting occurs with the pain,this
has occurred occassionally in the past
Bowel motions were soft and black over last 2 days
Has felt lethargic and weak
Long history of dyspepsia with periodic epigastric pain over last2
years (three episodes of pain over last 12 months, each lastingabout
2 or 3 weeks)
Takes over the counter ranitidine tablets for a week when painoccurs
Developed low back pain 3 weeks ago with X-rayof lumbarspine
showing moderate degenerative changes
Began taking diclofenac, prescribed for her husband and left inthe
bathroom cupboard since his death
Past Medical History
Barium meal many years ago showed a scarred stomach
Has osteoarthritis, particularly affecting the hips
Moderate hypertension for many years controlled withfelodipine
(slow release tablets)
Moderate chronic airflow limitation related to lifelongcigarette
smoking
Cholecystectomy 10 years ago for gallstones following episodesof
biliary colic
Caesarean section for birth of second child 50 years ago
Chest X-ray three years ago showed no abnormality
Current medications
Felodipine 10mg OD
Diclofenac 50 mg twice daily
Ranitidine 150 mg TID
Progress management
Transfused 2 units of packed red boold cells
Omeprazole 20 mg daily OD
Amoxycillin 500mg TID
Clarithromycin 500mg TID
Repeat haemoglobin 2 days later was 11.8 g/dL (NR12.0-16.0)
Endoscopy showed reduced (0.4 cm) gastric ulcer and no
signs of recent haemorrhage
Biopsies from ulcer edge were negative for malignancy
Multiple gastric antrum and corpus biopsies negative for H.
pylori
