WELLNESS PLAN

CLINICAL CASE
Identifying Data:

M.D. is a 30 year old female who

came in due to recurrent epigastric pain and nausea.
History of Present Illness
1 week prior to consult, noted onset of epigastric pain, non
crampy, gnawing in character non-radiating associated with nausea
aggravated by fatty meals and carbonated drinks. Patient self
medicated with ranitidine 150 mg tablet 2 x a day. Hyoscine (Buscopan)
and Aluminum Hydroxide + Magnesium Hydroxide (Kremil-S) Tablet 3 x
a day for 3 doses. No vomiting, no diarrhea, no fever, no dysuria. She
missed her work for the past 2 days and consulted to you clinic for
further management.
• Patient smokes 3-5 sticks per day for the past 5 years and drinks
alcohol almost every pay day to the point of intoxication.
• She tried to quit smoking and drinking for 2 months last year but later
on resumed. She has 3 sexual partners and had a son who is a 5 years
old from her first boyfriend.
• She works as a call center agent in a BPO industry for the past 5 years.
She claimed that she likes her work due to good pay except that night
shift work is quite tiresome. She felt that her workplace is very cold
and that she needs to wear sweater at all times.
• She is obese and her regular diet is usually prepared by herself
consisting of easily prepared food and occasional vegetables and
fruits. During her duty she drinks 2-3 cups of coffee.
• She loves hanging out with friends during off duty and has a plan to
go to the gym.
• She is the middle child among 5 siblings. Both parents are still alive
currently maintaining on hypertensive medications. Her mother was
diagnosed of diabetes 2 years ago. Her uncle died of Lung CA at the
age of 65 years old.
• You are on duty as a pre residency trainee at VCMC OPD. You
diagnosed her of functional dyspepsia. At this point you prescribe the
patient with home medication and advice to follow up a week after.
A. Identification of Risk Factors
NON- MODIFIABLE MODIFIABLE
• 30 years old • Call Center agent
• Female • Works in a cold environment
• G1P1 • Intake of coffee (3 cups per day)
• Family History: HPN on both sides, DM on the • Good pay but tiresome job ( esp. night shifts)
Maternal side, Uncle died of Lung CA • Smoker (0.75-1.25 pack years)
• Alcoholic Drinker ( twice a month)
• Sexually active with 3 sexual partners
• G1P1
• Obese
• Diet (Mostly easily prepared food)