Patient HL comes into the clinic with the following symptoms: nausea, vomiting, and

diarrhea. The patient has a history of drug abuse and possible Hepatitis C. HL is currently taking

the following prescription drugs:

Synthroid 100 mcg daily

Nifedipine 30 mg daily

Prednisone 10 mg daily

Consider whether the patient has a disorder related to the gastrointestinal and

hepatobiliary system or whether the symptoms are the result of a disorder from another system or

other factors such as pregnancy, drugs, or a psychological disorder.

Consider an appropriate drug therapy plan based on the patient’s history, diagnosis, and

drugs currently prescribed.

Based on information given, and the patient exhibiting symptoms of nausea, vomiting,

and diarrhea, a diagnosis of some form of a stomach virus also medically termed acute

gastroenteritis. Acute gastritis is a sudden inflammation or swelling in the lining of the stomach.

Symptoms can also cause abdominal pain, coupled with nausea, vomiting and fever may also

occur with these symptoms (Diskin, 2017). How the illness begins, spreads from contact to

contact with someone that may have already has been affected or eating contaminated food.

To alleviate the present symptoms and have the patient in the most comfortable care as

possible, a treatment protocol would consist of rehydration via saline fluids from loss of

vomiting and diarrhea. As a provider giving medical assistance, staff must always be cognizant

of reducing symptoms while preventing further complications (Arcangelo & Peterson, 2013).

In being aware of the patient’s current medications and previous drug history, drug

therapy and treatment plan would be consisting of non-habit-forming medications such as

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Phenergan and Zofran. Imodium A-D will also be prescribed to assist with diaherra. Patient will

be advised and instructed to be placed on a liquid diet which will consists of clear liquids,

electrolytes such Gatorade and Powerade will be strongly encouraged. Food recommendations

such as clear liquid broth, Jell-O, and Saltine crackers will also be recommended. Since the

patient is may also have Hep-C, additional testing may also be explored to test the patient’s liver

and conduct Hepatis C testing to see if the patient is at risk. During treatment of patient HL,

further and additional inquires would be asked to see why patient is taking Prednisone and what

is the patient taking this medication for? Prednisone side effects generally includes upset

stomach (Huether & McCance, 2017), but discontinuance of the medication would not be

encouraged, but a tapering of decreasing dosage would begin.

References

Arcangelo, P. V., & Peterson, A. M. (2013). Pharmacotherapeutics for Advanced Practice: A

Practical Approach (3rd ed.). Ambler, PA: Lippincott Williams &

Diskin, A. (2017, February 10). Emergent Treatment of Gastroenteritis. Medscape. Retrieved

from https://emedicine.medscape.com/article/775277-overview

Huether, S. E., & McCance, K. L. (2017). Understanding Pathophysiology (6th ed.). St. Louis,

Mo: Mosby

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Review of Case Study:

Patient HL comes into the clinic with the following symptoms: nausea, vomiting, and

diarrhea. The patient has a history of drug abuse, and possible Hepatitis C. HL is currently taking

the following prescription drugs: It is essential to complete a thorough health history and

examination before diagnosing HL. There are several necessary questions related to HL’s

medication list that should ask:

• Duration and reason for the Prednisone?

• Recent recreational drug use?

• Duration of the symptoms/ weightloss?

• Description and number of the stools/emesis per day?

• Synthroid 100 mcg daily

• Nifedipine 30 mg daily

• Prednisone 10 mg daily

History of Present Illness and Medical History

Patient presents with symptoms of diarrhea, nausea, and vomiting. Learning from HL’s

medical history, HL appears to have some possible chronic conditions based on his current

medications; Synthroid 100 mg daily, Nifedipine 30mg daily, and prednisone 10mg daily.

Synthroid is a hormone replacement that is used to treat hypothyroidism, thyroid

cancer and goiter (Drugs.com, 2017). Synthroid can have adverse effects if not taken correctly or

if misused, thorough assessment and review of patients understanding of medication regimen is

needed. Diarrhea is a common side effect of Synthroid. N/V are classified as severe/adverse

reaction and should be reported the health practitioner immediately (Drugs.com, 2017). Healthy

adults age 50 years or less with a weight of 70kg or more; initial dose of 100-125 mcg/day be

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taken for a few months. HL’s medical history and chronicity of the hepatitis could warrant

decreasing the current dose of Synthroid. Thyroid levels should be checked every 6-8 weeks

(Drugs.com, 2017). No warnings were identified with the use of Synthroid and Hepatitis C upon

review.

Nifedipine is a calcium channel blocker that is used to treat hypertension and chest

pain (angina). There are no warnings with Hepatitis C and the use of calcium channel blockers.

Initial dose recommended 30-60mg orally (Drugs.com, 2017). Nifedipine has also been linked to

several instances of clinically apparent acute liver injury, and dosing should be decreased for

patients with any chronic illness involving the liver and function. HL’s dose is appropriate for

treatment and current health status (Drugs.com, 2017).

Prednisone is a corticosteroid that prevents the release of substances in the body that

causes inflammation it also suppresses the immune system (Drugs.com.2017). Prednisone treats

many different conditions such as allergic disorders, skin conditions, ulcerative colitis, arthritis,

lupus, psoriasis, or breathing disorders. Prednisone should be taken with care if you have a

thyroid issue, and I recommend discontinuing this medication. Side effect of prednisone is

pancreatitis, which presents with severe pain in your upper stomach, nausea, and vomiting.

Prednisone often prescribed for HCV patients who are unresponsive to NSAIDs or have

advanced liver disease, such as cirrhosis, and in those who have contraindications to their use

(nephrotoxicity); short-term, low-dose prednisone (5 to 10 mg) is usually prescribed. Nifedipine

will increase the level or effect of prednisone (Drugs.com, 2017).

Assessment and Diagnostics

A comprehensive history and physical examination are required to create a full picture of

any underlining issues that is causing the patient’s symptoms. Medication reconciliation is

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needed to be conducted for potential drug interactions. Also, the diagnostic workup is required

for further evaluation. Drug Screen test, Urinalysis, abdominal ultrasound, Blood tests such as

liver panel, CBC, CMP, TSH, Hepatitis C RNA test, genotype test, an antibody test for HCV will

be ordered to determine the cause of the symptoms. Imaging of the GI tract for abnormalities

should be considered for thorough examination and ROS.

Primary Diagnosis: Hepatitis C Virus

Hepatitis C is an acute liver infection caused by a virus that usually results from infected

person-to-person contact of blood and bodily fluids, sexual intercourse or sharing of needles

associated with illicit drug/substance abuse (Arcangelo & Peterson, 2013) . classifications can be

acute or chronic (Arcangelo & Peterson, 2013). HCV is progressive, and in most cases,

symptoms are asymptomatic but may present significant problems. It is often undiagnosed due to

the symptoms present as a flu-like illness. Usually, elevated liver enzymes and a positive

antibody test for HCV (anti-HCV) mean that an individual has hepatitis C. Symptoms include

fatigue, mild fever, muscle and joint aches, nausea, vomiting, loss of appetite, vague abdominal

pain, and sometimes diarrhea. Diarrhea develops during acute hepatitis C. Although this initial

phase of infection causes no symptoms at all, approximately 20 to 30 percent of people notice

symptoms about 1 to 3 months after contracting the virus (Centers for Disease Control and

Prevention, 2016). From the data collected, the patient has a history drug abuse, the current

medications such as prednisone and presenting symptoms may suggest the diagnosis of Acute

Hepatitis C.

Differential Diagnosis

• Drug Dependence and Abuse: The signs and symptoms displayed by a person

depend on what substances the person has abused. Symptoms may include altered mental status,

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CNS suppression, nausea, vomiting, diarrhea, anxiety, hallucinations, chest pain, and abdominal

pain. Most patients with substance abuse commonly exhibit behavioral symptoms that can cause

harm to self or others and requires an emergent medical intervention(Arcangelo & Peterson,

2013). Referral to dependence counselor or addiction specialist is warranted to rule out acute

relapse.

• Gastroenteritis is irritation/inflammation of the stomach and intestines caused by

food contaminated with bacteria, viruses, parasites, or toxins. Symptoms may include cramping,

nausea, vomiting, or diarrhea. The illness usually spreads easily from contact with a sick person

or eating or drinking contaminated food or beverages also will spread the disease. Most

otherwise healthy patients recover in a few days by drinking plenty of fluids and resting.

Antibiotics treat gastroenteritis caused by bacteria or some parasites. In most cases, nausea,

vomiting, and diarrhea will resolve within 24 to 48 hours (Arcangelo & Peterson, 2013).

-Offering the patient an antiemetic would be an appropriate intervention and may provide

comfort.

Plan and Treatment Recommendations

According to the American Association for the Study of Liver Diseases and the Infectious

Diseases Society of America (2016), the recommendations for treatment and management per

HCV Guidelines:

Regular laboratory monitoring every four to six weeks for six months to 12 months is

also recommended to determine spontaneous clearance of HCV infection versus persistence of

infection (Drugs.com, 2017).

HL’s symptomology and presentation it is my belief the patient can be classified as genotype

1a (without cirrhosis) (Drugs.com, 2017). Guidelines for the diagnosis and management of HCV

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infection were originally released jointly by the American Association for the Study of Liver

Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) in 2016 and are

updated on a continuous basis, following availability of new medications or release of major

treatment trials. Regimen selection for patients with genotype 1 infection should take into

account the efficacy, duration, and adverse reactions, potential drug interactions, the patient's

history of prior treatment, and the stage of fibrosis before selecting the best medication to treat

(Arcangelo & Peterson, 2013)

References:

Arcangelo, V. P., & Peterson, A. M. (2013). Pharmacotherapeutics for Advanced Practice: A

practical approach. Ambler, PA: Lippincott Williams and Wilkins.

American Association for the Study of Liver Diseases and the Infectious Diseases Society of

America (2016). Management of Acute HCV Infection. Retrieved July 9, 2018 from

http://www.hcvguidelines.org/unique-populations/acute-infection

Centers for Disease Control and Prevention (2016). Hepatitis C FAQs for the Public.

Retrieved July 9, 2018 from https://www.cdc.gov/hepatitis/hcv/cfaq.htm

http://symptoms.webmd.com/default.htm#conditionView

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Hypertension if left without treatment can causes nausea and vomiting as presenting

symptoms. This nausea and vomiting can also be a sign of a heart attack a comprehensive lab

work-up to ensure there is no damage to the heart must be complete for the visit to be thorough

in diagnosing and treatment. Multiple or continuous blood pressure measurements should be

ordered if they could be responsible for the symptoms.

Arcangelo, V. P., & Peterson, A. M. (2013). Pharmacotherapeutics for Advanced Practice: A

practical approach. Ambler, PA: Lippincott Williams and Wilkins.

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Adenike B.docx by Adenike Balogun

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