Clinical case presentation Please add the pathophisiology. most of the job is done, see attached documentation

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clinicalcasepresentation.docx

Chief complaint: "Penfigo Vulgaris" HPI: Mr. Agustin is a 81 year old male, presenting today to the clinic for annual visit and follow up. Allergies: Latex Leg Strap Set/Buttons: hives:  Side Effects Latex Leg Strap/Button: hives: Side Effects Ciprofloxacin: vomiting: Side Effects Iodine: anaphylaxis: Allergy Lactose: diarrhea: Allergy Chlorhexidine: rash: Side Effects Social History: 81 years old male denies smoking, alcohol intake occasionally. Denies illicit drugs.  Past Medical History: Hypertension. Arthritis. Barretts esophagus. Dr. ALfredo Rabbasa. Hyperlipidemia. coronary artery disease x 1stent (1995). Cardiology Dr. Joaquin Diego. Urinary Incontinence. Dr. Carlos Santa Cruz. Atherosclerosis of aorta. Atherosclerosis of native arteries of extremities with rest pain, bilateral legs. Medications: Taking - Lipitor 20 MG Tablet 1tablet Orally Once a day - Imuran 50 MG Tablet 1tablet Orally TID - Triamterene-HCTZ 37.5-25 MG Tablet 1 tablet in the morning Orally Once a day - Tylenol PM Extra Strength 500-25 MG Tablet 1tablet at bedtime as needed Orally Once a day - Omeprazole 20 MG Capsule Delayed Release 1capsule Orally Once a day - Diclofenac Sodium 50 MG Tablet Delayed Release 1tablet with food or milk Orally once a day - Metoprolol Succinate ER 25 MG Tablet Extended Release 24 Hour 1tablet Orally Once a day - Mupirocin 2 % Ointment 1application to affected area Externally Three times a day - Myrbetriq 25 MG Tablet Extended Release 24 Hour 1tablet Orally Once a day - Clorazepate Dipotassium 3.75 MG Tablet 1 tablet Orally Once a day at bed time - Fluocinonide 0.05 % Cream Apply Topically Externally BID - PredniSONE 10 MG Tablet 1tablet Orally Once a day Discontinued - Triamterene-HCTZ 37.5-25 MG Tablet 1 tablet in the morning Orally Once a day - Lipitor 20 MG Tablet 1tablet Orally Once a day - Nystatin 100000 UNIT /ML Suspension 4 ml Mouth/Throat Four times a day - Lipitor 20 MGTablet 1tablet Orally Once a day - Aspirin 81MG Tablet Chewable 1tablet Orally Once a day - Meclizine HCl 25 MG Tablet 1tablet as needed Orally twice a day - Probiotic - Capsule Orally - Triamterene-HCTZ 37.5-25 MG Tablet 1 tablet in the morning Orally Once a day - Medication List reviewed and reconciled with the patient ROS: All body systems in remarkable state, within normal limitations  Vital Signs: T: 98.2 BP (left arm): 110/70 P: 81 RR: 18 Weight: 128 lbs High: 5'11"  General: Patient AAO x3, well nourished, no acute distress, also denies weight change, fatigue, fever, chills, or night sweats. HEAD: normocephalic, atraumatic. EYES: pupils equal, round, reactive to light and accommodation. EARS: normal ORAL CAVITY: mucosa moist. THROAT: clear NECK/THYROID: neck supple, full range of motion, no cervical lymphadenopathy. SKIN: no suspicious lesions, warm and dry. HEART: no murmurs, regular rate and rhythm, S1, S2 normal. LUNGS: clear to auscultation bilaterally. ABDOMEN: normal, bowel sounds present, soft, nontender, nondistended. No hepatic or spleen enlargement. No masses palpated. THORAX & LUNGS: Equal thoracic expansion. Breath sounds clear to auscultation bilaterally, unlabored respirations, no accessory muscle use or retractions. No rhonchi, wheezing, or rales. No tenderness on palpation or percussion of chest wall or spine. Upon percussion, there is tympani bilaterally and symmetrically. CARDIOVASCULAR: No chest pain or palpitations. GASTROINTESTINAL: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. Patient reports having daily bowl movements. GENITOURINARY: No hematuria, or dysuria. Nervous System: Gross sensation intact. Coordination is intact. Gait is stable and grossly intact. MS: Cap refill <3 seconds. Upper extremities with Radial pulses 2+/4 noted bilaterally, strength testing 5/5 bilaterally, ROM intact. Lower Extremities with Dorsalis pedals pulses 2+/4. Psych: Patient cooperative, denies history of depression, and anxiety. Lymphadenopathy: No palpable lymphadenopathies. ASSESSMENT/PLAN: 1. Encounter for general adult medical examination with abnormal findings - ZOO.01(Primary) 2. Chronic fatigue, unspecified - Rs3.82 3. Essential (primary) hypertension - 110 4. Hyperlipidemia, unspecified - E78.5 5. Lumbago with sciatica, unspecified side - M54-40 6. Other abnormalities of gait and mobility - R26.89 7. Gastro-esophageal reflux disease without esophagitis - K21.9 8. Other specified urinary incontinence - N39.498 9. Bladder-neck obstruction - N32.0 10. Benign prostatic hyperplasia with lower urinary tract symptoms - N40.1 11.Urethral stricture, unspecified - N35.9 12. Actinic keratosis - L57.0 13. Herpesviral infection, unspecified - BOO.9 14. Cutaneous abscess of left lower limb - L02-416 15. Cellulitis of abdominal wall- L03.311 16. Atherosclerotic heart disease of native coronary artery without angina pectoris - 125.10 17.Atherosclerosis of native arteries of extremities with rest pain, bilateral legs - 170.223 18. Coronary angioplasty status - Z98.61 19. Atherosclerosis of aorta - 170.0 20. Benign paroxysmal vertigo, bilateral- H81.13 21. Insomnia, unspecified - G47.00 22. Rash and other nonspecific skin eruption - R21 23. Body mass index (BM!) 21.0-21.9, adult - Z68.21 24. Encounter for screening for malignant neoplasm of colon - Z12.11 25. Encounter for screening for malignant neoplasm of prostate - Z12.5 26. Pemphigus vulgaris - L1O.0  Diagnosis: Chronic fatigue Plan: 1. Encounter for general adult medical examination with abnormal findings LAB:TSH (Ordered for 06/18/2018) LAB: HEMOGLOBIN AlC (Ordered for 06/18/2018) 2. Essential (primary) hypertension Refill Triamterene-HCTZ Tablet, 37.5-25 MG, 1tablet in the morning, Orally, Once a day, 90 days, 90, Refills 1 Refill Metoprolol Succinate ER Tablet Extended Release 24 Hour, 25 MG, 1tablet, Orally, Once a day, 90 days, 90 Tablet, Refills 3  Referral To:Victor Pazos Cardiology  Reason: Evaluation 3. Hyperlipidemia, unspecified Refill Lipitor Tablet, 20 MG, 1tablet, Orally, Once a day, 90 days, 90, Refills 1 LAB: Lipid Panel (Ordered for 06/18/2018) 4. Lumbago with sciatica, unspecified side Refill Tylenol PM Extra Strength Tablet, 500-25 MG, 1tablet at bedtime as needed, Orally, Once a day, 90 days, 90, Refills 1 Refill Diclofenac Sodium Tablet Delayed Release, 50 MG, 1 tablet with food or milk, Orally, once a day, 90 days, 90, Refills 1 Refill Probiotic Capsule, -, Orally, 90 days, Refills 1 5. Gastro-esophageal reflux disease without esophagitis Refill Omeprazole Capsule Delayed Release, 20 MG, 1 capsule, Orally, Once a day, 90 days, 90, Refills 1 6. Other specified urinary incontinence Refill Myrbetriq Tablet Extended Release 24 Hour, 25 MG, 1tablet, Orally, Once a day, 30 dayts), 30 7. Cutaneous abscess of left lower limb Refill Mupirocin Ointment, 2 %, 1 application to affected area, Externally, Three times a day 8. Coronary angioplasty status Refill Aspirin Tablet Chewable, 81 MG, 1tablet, Orally, Once a day, 90 days, 90, Refills 1 9. Insomnia, unspecified Refill Clorazepate Dipotassium Tablet, 3.75 MG, 1tablet, Orally, Once a day at bed time, 90 days, Refills 1 10. Rash and other nonspecific skin eruption Refill Fluocinonide Cream, 0.05 %, Apply Topically, Externally, BID, 90 days, 120 Gram, Refills 0 Refill PredniSONE Tablet, 10MG, 1tablet, Orally, Once a day, 30 days, 30 Tablet, Refills 0 11. Encounter for screening for malignant neoplasm of colon LAB: Occult Blood, Fecal, IA (Ordered for 06/18/2018) 12. Encounter for screening for malignant neoplasm of prostate LAB: PSA Total (Reflex To Free) (Ordered for 06/18/2018) 13. Others Refill Lipitor Tablet, 20 MG, 1tablet, Orally, Once a day, 90, 90 Tablet, Refills 3 Refill Triamterene-HCTZ Tablet, 37.5-25 MG, 1tablet in the morning, Orally, Once a day, 90, 90 Tablet, Refills 3 Refill Lipitor Tablet, 20 MG, 1tablet, Orally, Once a day, 90, 90 Tablet, Refills 3 Refill Nystatin Suspension, 100000 UNIT/ML, 4 ml, Mouth/Throat, Four times a day, 30 day(s), 480, Refills 1 Refill Meclizine HCI Tablet, 25 MG, 1tablet as needed, Orally, twice a day Teaching: Colorectal Cancer Screening: The Recommended Frequency is: Every 10 years, Colonoscopy Screening for colorectal cancer was last done on: "3-4 years ago, wnl." Follow Up: 4 Weeks (Reason: follow up labs)