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Case Study 8 Richard (27 yo; male) presents to his local GP with right sided abdominal pain (“under my ribcage”), yellowing of the whites of the eyes, he feels generally unwell, and had a fever last night of 38.7oC. Richard has recently returned from a trip to Asia, where he ate “like a local”, buying from many of the street-side vendors and drinking locally prepared drinks. He reports he’s been feeling tired for about a week now. He insists he uses condoms anytime he has sex, and that he wasn’t
sexually active on this trip away.
Richard’s past medical history includes nothing remarkable except for a bout of gall stones “about two years ago”, that was treated with laparoscopic cholecystectomy.
Richard’s currently takes not regular medications.
Richard’s family history includes:
• Alcoholic mother and father
• Mother deceased at 52 yo
• Father living (64 yo); has Type 2 Diabetes
• Two siblings; both apparently well
Richard’s social history includes:
• Currently single; never married; lives in a share house with four other people
• Sexually active; multiple partners
• Employed; IT consultant
• Non-smoker
• Social drinker (weekends only; admits to “binging”)
• Minimal caffeine consumption
• Regular illicit drug use; injecting, smoking, and snorting
• Regular, daily exercise
Physical Examination:
• Male, 27 yo, Anglo-Saxon heritage
• Height 6’ 2” (188 cm)
• Weight 88 kg
• Blood Pressure 138/80
• Heart Rate 69 bpm
• Respiration Rate 16 per minute
• Temperature 38.1oC

• Several tattoos: arms, legs and torso
• No obvious hepato-splenomegly

Introduction
Set the scene for your readers (lay audience). Give background on the body system under study and the specific pathophysiological state of your Case Study. Provide information that will assist your readers to understand your report, and point them down the road to logically assess and understand what you are writing about with regards to your patient, the disease, and treatment options available, and the likely outcome(s).

Patient (Case Study) Outline 
Quick summary of your Case Study. Link it to your introduction and your “discussion/conclusion” (ie the rest of your report).
Critical Analysis – What are the treatment options? 
Identify, state, and explain treatment options available; then state and justify your chosen treatment regime.

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  • Uploaded By : Keith
  • Posted on : September 26th, 2018
  • Downloads : 403

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