Student Name: Rapadas, Hanz Alec O.

Date: March 04, 2021

Section: BSN 3201
CASE STUDY FOR PEPTIC ULCER

Residents Name: Rapadas, Hanz Alec O.

Date: March 04, 2021
Patient Identification (For confidentiality)
Initials: N.A
Age: 79 years old
Address: Padre Garcia, Batangas
Marital Status: N.A
Religion: N.A
Medical History
Chief Complaint: Upper abdominal pain and black
stool for the last 2 days
Present Medical History
For the past two days, the patient has had an
epigastric burning feeling. Her pain is fairly intense but
not radiating, and it is eased to some extent by eating
and taking Gaviscon, an antacid. She has no history of
weight loss, but she does vomit when she is in pain, as
she has done in the past. For the last two days, her
bowel movements have been sluggish and black, and
she has felt lethargic and tired. Furthermore, over the
last two years, there has been a long history of
dyspepsia with intermittent epigastric pain (three
episodes of pain over last 12 months, each lasting about
2 or 3 weeks). When the pain flares up, she now takes
over-the-counter ranitidine pills for a week. In
addition, she began experiencing low back pain three
weeks ago, and an X-ray of her lumbar spine revealed
mild degenerative changes. Then she started taking
diclofenac, which had been left in the bathroom cabinet
after her husband's death.
Past Medical History
Many years before, the patient's Barium meal
revealed a scarred stomach. She has osteoarthritis in
her hips and has had mild hypertension for several
years, which she has managed with felodipine (slow-
release tablets). In addition, lifelong cigarette smoking
causes a mild persistent airflow restriction. Following
episodes of biliary colic, she had a cholecystectomy 10
years ago for gallstones. She also had a Caesarean
section 50 years ago for the birth of her second child.
Three years ago, an X-ray of her chest revealed no
abnormalities.
Current medications
Felodipine 10mg OD
Diclofenac 50 mg twice daily
Ranitidine 150 mg TID
Problems
- She has an upper abdominal pain and defecates
black stool for the last 2 days
- There is a presence of an epigastric burning
sensation
- The patient also vomits but no weight loss
detected
- Patient feels lethargic and weak
- Has developed low back pain 3 weeks ago
Plan of Action
(See next page)
Possible Evaluation/Outcome
The patient has verbalized relief of pain. and has
demonstrated a relaxed body posture and be able to rest
properly.