Advanced Primary Care of Family Practicum I

Patient Initials: CK

Pt. Encounter Number: 1

Date: 02/10/2021

Age:72

Sex: M

Allergies: NKA Advanced Directives: NONE

SUBJECTIVE

CC:

“Abdominal pain, fever, nausea and vomiting”

HPI: Mr C. K. is a 72-year-old male who visited the clinic c/o left lower abdominal pain, low grade fever, nausea and vomiting. He states that his symptoms started 2 days ago after eating dinner in one of the restaurant. Patient has a history of diabetes, hypertension, and hypercholesterolemia that are controlled with oral medications. He denies any recent trauma, epigastric pain, and constipation. Patient is a truck driver and often repairs his own truck. He stated that he did some major repairs on his truck 2 weeks ago that involve heavy lifting and hammering out old parts from the truck. He has been taking Advil 200 mg, 2 tabs in the morning and evening for his aching joints and muscles. Patient takes OTC Vitamin D, Calcium and Fish oil. He also drinks two cups of coffee daily to stay awake on the road.

Current Medications:

Lisinopril 10 mg PO daily for HTN Metformin 500 mg PO BID for Diabetes Zocor 20 mg PO daily for High cholesterol Advil 400 mg PO BID PRN for pain Vitamin D, Calcium and Fish oil PO daily

PMH

Medication Intolerances: NONE

Chronic Illnesses/Major traumas: HTN, DM, Hypercholesterolemia

Hospitalizations/Surgeries: Back Surgery in 2003

Family History:

Mother: HTN, DM, Hypercholesterolemia, and stroke. Died at age 69. Father: Arthritis, HTN, DM, CAD, COPD and ESRD.

Social History:

Truck driver, divorce, has two children and lives with girlfriend. Denies use of ETOH, but smokes 1pack cigarette per day.

ROS

General

Patient states he is feeling weak, has hand tremors, fever, nausea, and vomiting. Denies epigastric pain, chills and night sweats.

Weight change, fatigue, fever, chills, night sweats, energy level

Cardiovascular

Denies CP/SOB/Palpitations.
Chest pain, palpitations, PND, orthopnea, edema

Skin

Denies rash, bruising or bleeding. Denies delayed healing or changes in skin color or moles.

Respiratory

Denies cough/wheezing. Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB

Eyes

Denies blurry visson or eye pain


Gastrointestinal

Patient has nausea, vomiting and abdominal pain

Ears

Denies ear pain, hearing loss or ringing in ears.

Genitourinary/Gynecological

Denies frequency, urgency, dysuria.

Nose/Mouth/Throat

Denies sinus problems, nose bleeds, runny nose, throat pain, or dysphagia.

Musculoskeletal

Has joint pain and stiffness daily related to repair on his truck, takes OTC Advil every AM and PM.

Breast

Denies any lumps, bumps, or changes.

Neurological

Patient has weakness and hand tremors. Denies dizziness, syncope, or neurological changes.

Heme/Lymph/Endo

No lymph node swelling

Psychiatric

Denies depression, anxiety, insomnia.

OBJECTIVE

Weight 220 BMI 29

Temp 99.2

BP 145/82

Height 6’1

Pulse 100

Resp 18

PHYSICAL EXAMINATION

General Appearance

Alert and oriented; answers questions appropriately and well develop.

Skin Intact, warm and dry with no bruising, lesions, or rashes. No cyanosis or clubbing noted.

HEENT

Head: Head is normocephalic, atraumatic and without lesions; hair evenly distributed.

Eyes: conjunctivae, EOM and lids are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge. No sclera icterus.

Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular

RRR, S1 and S2. No S3, S4 rubs, murmurs, clicks, snaps or gallops noted. No thrills, heaves, or lifts with palpation.

Peripheral Vascular: No cyanosis, clubbing. Radial pulses 3+ bilaterally. PT/DP pulse 2+ bilaterally.

Respiratory

Symmetrical chest expansion. Respirations regular and unlabored with diminished breath sound bilaterally. Lungs clear to auscultation bilaterally. No wheezing, rhonchi, or stridor.

Gastrointestinal

Abdominal flat, soft and non-distended. Bowel sounds present in all four quadrants. Abdominal tender to left lower quadrant with palpitation.

Breast

Free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Genitourinary

No bladder tenderness on palpation.

Musculoskeletal

Full ROM seen in all four extremities as the patient moved about the exam room

Neurological

Speech clear. Good tone. Balance stable; gait normal .


Psychiatric

He alert and oriented x3. Patient has a normal mood and affect. His behavior is normal. Thought content normal.

Lab Tests

CBC-pending CMP-pending Stool-occult


Special Tests

CT abdomen with oral contrast

Diagnosis

Differential Diagnoses

o 1- Gastroenteritis o 2- Colitis
o 3- Diverticulitis

Diagnosis
o Diverticulitis

Plan:
GI consultation for further evaluation
Medication: For nausea and vomiting- Zofran 4 mg SL every 6 hours as needed.

For diverticulitis – Metronidazole 500 mg TID PO plus Ciprofloxacin 500mg

BID PO for 10 days.

· Education: Diverticulitis can be caused by chronic Advil use. This wears the 
intestinal lining and can cause inflammation. 


· Non-medication treatments: High fiber diet 


· Follow-up: Return to clinic if symptoms worsen. ED precautions reviewed with 
patient. Lightheadedness, weakness, dizziness, severe abdominal pain, inability to telerate oral intake or failure to improve with outpatient management, the patient should go to nearest Emergency Room. 


References

References

Buttaro, T. M., & Sandberg_Cook, J. (2013). Primary care. A collaborative practice. St. Louis: Mosby, Inc.

Grossman, S. C., & Porth, C. M. (2014). Porth's pathophysiology. Concepts of altered health states. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

MD, L. B. (2012). Bates' guide to physical examination and history taking, 11th Edition. [VitalSource Bookshelf version]. Retrieved from http://digitalbookshelf.southuniversity.edu/books/9781469825106/outline/11