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Microsoft word - ust case-feb2011.doc

UNIVERSITY OF CONNECTICUT/CT AHEC
URBAN SERVICE TRACK

Case of AB
CC:
“I can’t swallow my pills because my stomach hurts.”
HPI: AB is a 65 yo Hispanic female who speaks very limited English that is difficult to
understand. She presents to clinic with a complaint of difficulty swallowing and taking
medications secondary to dysphagia, bloating, and abdominal pain, which have been present on
and off for several months. She states she tries to take her medications anyway by dissolving the
tablets in a glass of water, then drinking the glass of water. AB also c/o gas and an “acid” taste in
her mouth. She states that she can only eat a small amount of food. She also complains that the
food “gets stuck in my throat”, and experiences early satiety. She reports having episodes of
vomiting after eating, as well as episodes of diarrhea and constipation.
PMH: Type 2 DM (diabetes mellitus), HTN (hypertension), hyperlipidemia, OCD (obsessive
compulsive disorder), depression/anxiety, h/o irritable bowel syndrome
Allergies: NKDA (no known drug allergies)
Medications:
paliperidone (Invega) 3 mg QHS – hasn’t taken in 2 months
lorazepam (Ativan) 0.5 mg BID prn – hasn’t taken in 2 months
amlodipine (Norvasc) 5 mg daily
metoprolol succinate (Toprol XL) 25 mg daily
glyburide 5 mg BID
valsartan (Diovan) 320 mg daily
esomeprazole (Nexium) 20 mg daily
sertraline (Zoloft) 100 mg BID
simvastatin (Zocor) 80 mg daily
aspirin 81 mg daily
Payer Source: Medicaid (Title 19)
SH: lives alone; denies tobacco, alcohol, or illicit drugs
Vitals/Labs: (No meds taken today)
Wt 180 lbs
BP (sitting, L arm, reg cuff): 150/75 mmHg P 80 RRR Created by Devra Dang, PharmD & Ruth Goldblatt, DMD, University of Connecticut (01/10)
Property of the University of Connecticut Urban Service Track
Permission required for use and duplication (clarkdufner@uchc.edu)

UNIVERSITY OF CONNECTICUT/CT AHEC
URBAN SERVICE TRACK
Questions for students to discuss in groups:
1. What additional information would you ask the patient in order to make a full
assessment? Make a list of all the information you want to obtain from the patient and the
rationale for each question. You will ask the “patient” (role-played by a faculty member)
these questions but remember that in real-life scenarios, you may be constrained by time
limits. Therefore, prioritize the questions from most to least important. If there is any
information that you would need to get from the medical chart, ask these questions as well.
If the information is available, the health care provider taking care of AB (role-played by a
faculty member) will provide this information.
2. What is your assessment and plan for helping this patient? (Answer this question after
you have obtained the information from the “patient” and “chart” and completed the next
2 learning activities.)

Created by Devra Dang, PharmD & Ruth Goldblatt, DMD, University of Connecticut (01/10)
Property of the University of Connecticut Urban Service Track
Permission required for use and duplication (clarkdufner@uchc.edu)

Source: http://www.adea.org/publications/library/2011annualsession/Documents/D_92_217926_202635.pdf

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