mod 1. AdvHealth-Discussion

Case Study 1

Chief Complaint

(CC) “I came for my annual physical exam, but do not want to be a burden to my daughter.”

History of Present Illness (HPI) At-risk 86-year-old Asian male – who is physically and financially dependent on his daughter, a single mother who has little time or money for her father’s health needs.

PMH Hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis

PSH S/P cholecystectomy

Drug Hx Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily.

Allergies:

Family Hx: 

General+ weight loss of 25 lbs over the past year; no recent fatigue, fever, or chills.

Head, Eyes, Ears, Nose & Throat (HEENT)No changes in vision or hearing, no difficulty chewing or swallowing.

Neck No pain or injury 

Respiratory

CV

GI

GUno urinary hesitancy or change in urine stream

Integumentmultiple bruises on his upper arms and back.

MS/Neuro+ falls x 2 within the last 6 months; no syncopal episodes or dizziness

PE B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8

General

HEENTAtraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.

Lungs CTA AP&L

Cardio S1S2 without rub or gallop

Abdomen benign, normoactive bowel sounds x 4

GU

Extremities no cyanosis, clubbing or edema

Integumentary multiple bruises in different stages of healing – on his upper arms and back.

MS

Neuro No obvious deformities, CN grossly intact II-XII