Mr. E is a pleasant, 70-year-old, black, maleSource Self, rel.docx
0 j'aime
vues
Jasleen morning report 1
Mr. E is a pleasant, 70-year-old, black, maleSource Self, rel.docx
0 j'aime
vues
Mr. E is a pleasant, 70-year-old, black, male Source: Self, reliable source Subjective: Chief complaint: “I urinate frequently.” HPI: Patient states that he has had an increase in urination for the past several years, which seems to be worsening over the past year. He estimates that he urinates clear/light yellow urine approximately every 1.5-2 hours while awake and is up 2-4 times at night to urinate. He states some urgency and hesitancy with urination and feeling of incomplete voiding. He denies any pain or blood. Denies any head trauma. Denies any increase in thirst or hunger. He denies any unintentional weight loss. Allergies : NKA Current Mediations : Multivitamin, daily Aspirin, 81 mg, daily Olmesartan, 20 mg daily Atorvastatin, 10 mg daily Diphenhydramine, 50 mg, at night Pertinent History: Hypertension, hyperlipidemia, insomnia Health Maintenance. Immunizations: Immunizations up to date Family History: No cancer, cardiac, pulmonary or autoimmune disease in immediate family members Social History: Patient lives alone. He drinks one cup of caffeinated coffee each morning at the local diner. He denies any nicotine, alcohol or drug use. ROS: Incorporated into HPI Objective: VS – BP: 118/68, HR: 86, RR: 16, Temp 97.6, oxygenation 100%, weight: 195 lbs, height: 70 inches. Mr. E is alert, awake, oriented x 3. Patient is clean and dressed appropriate for age. Cardiac: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop Respiratory: Clear to auscultation Abdomen: Bowel sounds positive. Soft, nontender, nondistended, no hepatomegaly Neuro: CN 2-12 intact Renal/prostate: Prostate enlarged, non-tender. No asymmetry or nodules palpated Labs: Test Name Result Units Reference Range Color Yellow Yellow Clarity Clear Clear Bilirubin Negative Negative Specific Gravity 1.011 1.003-1.030 Blood Negative Negative pH 7.5 4.5-8.0 Nitrite Negative Negative Leukocyte esterase Negative Negative Glucose Negative mg/dL Negative Ketones Negative mg/dL Negative Protein Negative mg/dL Negative WBC Negative /hpf Negative RBC Negative /hpf Negative Lab Pt’s Result Range Units Sodium 137 136-145 mmol/L Potassium 4.7 3.5-5.1 mmol/L Chloride 102 98-107 mmol/L CO2 30 21-32 mmol/L Glucose 92 70-99 mg/dL BUN 7 6-25 mg/dL Creat 1.6 .8-1.3 mg/dL GFR 50 >60 Calcium 9.6 8.2-10.2 mg/dL Total Protein 8.0 6.4-8.2 g/dL Albumin 4.5 3.2-4.7 g/dL Bilirubin 1.1 <1.1 mg/dL Alkaline Phosphatase 94 26-137 U/L AST 25 0-37 U/L ALT 55 15-65 U/L Pt’s results Normal Range Units WBC 9.9 3.4 - 10.8 x10E3/uL RBC 4.0 3.77 - 5.28 x10E6/uL Hemoglobin 11.5 11.1 - 15.9 g/dL H.
Recommandé
Mr. E is a pleasant, 70-year-old, black, maleSource Self, rel.docx
- Mr. E is a pleasant, 70-year-old, black, male Source: Self, reliable source Subjective: Chief complaint: “I urinate frequently.” HPI: Patient states that he has had an increase in urination for the past several years, which seems to be worsening over the past year. He estimates that he urinates clear/light yellow urine approximately every 1.5-2 hours while awake and is up 2-4 times at night to urinate. He states some urgency and hesitancy with urination and feeling of incomplete voiding. He denies any pain or blood. Denies any head trauma. Denies any increase in thirst or hunger. He denies any unintentional weight loss. Allergies : NKA Current Mediations : Multivitamin, daily Aspirin, 81 mg, daily Olmesartan, 20 mg daily Atorvastatin, 10 mg daily Diphenhydramine, 50 mg, at night
- Pertinent History: Hypertension, hyperlipidemia, insomnia Health Maintenance. Immunizations: Immunizations up to date Family History: No cancer, cardiac, pulmonary or autoimmune disease in immediate family members Social History: Patient lives alone. He drinks one cup of caffeinated coffee each morning at the local diner. He denies any nicotine, alcohol or drug use. ROS: Incorporated into HPI Objective: VS – BP: 118/68, HR: 86, RR: 16, Temp 97.6, oxygenation 100%, weight: 195 lbs, height: 70 inches. Mr. E is alert, awake, oriented x 3. Patient is clean and dressed appropriate for age. Cardiac: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop Respiratory: Clear to auscultation Abdomen: Bowel sounds positive. Soft, nontender,
- nondistended, no hepatomegaly Neuro: CN 2-12 intact Renal/prostate: Prostate enlarged, non-tender. No asymmetry or nodules palpated Labs: Test Name Result Units Reference Range Color Yellow Yellow Clarity Clear Clear Bilirubin Negative Negative
- Specific Gravity 1.011 1.003-1.030 Blood Negative Negative pH 7.5 4.5-8.0 Nitrite Negative Negative Leukocyte esterase Negative Negative Glucose Negative mg/dL
- Negative Ketones Negative mg/dL Negative Protein Negative mg/dL Negative WBC Negative /hpf Negative RBC Negative /hpf Negative Lab
- Pt’s Result Range Units Sodium 137 136-145 mmol/L Potassium 4.7 3.5-5.1 mmol/L Chloride 102 98-107 mmol/L CO2 30 21-32
- mmol/L Glucose 92 70-99 mg/dL BUN 7 6-25 mg/dL Creat 1.6 .8-1.3 mg/dL GFR 50 >60 Calcium 9.6
- 8.2-10.2 mg/dL Total Protein 8.0 6.4-8.2 g/dL Albumin 4.5 3.2-4.7 g/dL Bilirubin 1.1 <1.1 mg/dL Alkaline Phosphatase 94 26-137 U/L
- AST 25 0-37 U/L ALT 55 15-65 U/L Pt’s results Normal Range Units WBC 9.9 3.4 - 10.8 x10E3/uL RBC 4.0 3.77 - 5.28
- x10E6/uL Hemoglobin 11.5 11.1 - 15.9 g/dL Hematocrit 35.0 34.0 - 46.6 % MCV 85 79 - 97 FL MCH 28 26.6 - 33.0 Pg MCHC
- 34 31.5 - 35.7 g/dL RDW 14 12.3 - 15.4 % Platelets 220 150 - 379 X10E3/uL PSA 5.4 0-4.0 ng/mL Assessment: Diagnosis: Benign prostatic hyperplasia, ICD-10: N40.1
- Please answer the following: For the sake of this case study, the patient has confirmed BPH and prostate cancer has already been ruled out. Hence, please document your prescribed treatment plan for this patient (i.e. don’t state “refer to urology”). What is your treatment plan (include specific dosage and frequency)? Why did you choose this treatment plan? Do you change any of his current medications? In your answer, please describe, briefly, the pharmacodynamics (1 point) and pharmacokinetics (1 point) of your treatment choice and how they influenced your decision. Does the patient have any comorbidities that influenced your choice as well (1 point)? Three months later, the patient notes improvement, but no resolution of symptoms. What would be your next prescribed treatment option (1 point)? Document the education you would provide for this patient, specific to the prescribed medication. Please include information pertinent to the patient (2 points) and common potential adverse effects (2 points).