case study

Mr. Brown is a 65 year old African American male who presents to the clinic for a physical exam. He has not seen a provider in over 10 years and is here at the insistence of his wife. Lately he has been experiencing more “heartburn after I eat” but “nothing that I can’t live with.” Mr. Brown reports taking over the counter Pepcid about 2-3 times a week with some relief. Other than the reflux type symptoms, he denies any other medical issues. He just needed to get a checkup.Allergies: Strawberries, NKDACurrent medications: Pepcid OTC as neededPMH: GERD,PSH: Tonsillectomy, appendectomySocial: Tobacco: 1 PPD, Alcohol: 2-3 drinks every 3-4 days, Denies illegal drug use. He works fulltime at Lowe’s, does report some heavy lifting. He is married with 2 grown sons and 5 grandchildren. In a monogamous relationship. He is active, coaching little league football.Immunizations: unsureFamily: Father: died at 72 of MI, Mother: died at 60 of breast cancerROS:Constitional:HEENT: Denies any headache, nasal congestion, ear painCardiovascular: Denies chest painRespiratory: Denies any SOB, DOE, orthnopeniaGI: Reports some burning pain at times, feels like heartburn.GU: Denies any painful urination, urgency, hesitancyMusculoskeletal: Reports some knee pain with bending, walking long distances. Denies any swelling or rednessNeurological: DeniesPsychiatric: Denies suidicial ideations, depression. Does report difficulty falling asleepEndocrine: Reports he has lost about 10 pounds over the last few months.Hematologic/ Lymphatic: Denies any bruisingOBJECTIVE:Vital signs: Ht: 70, Wt: 265, BP 178/94, HR 92, Resp: 16, SaO2: 95%Constitutional: Well developed, obese maleHEENT: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable massesCardiovascular: RRR, No murmurs or rubs noted. No peripheral edema notedRespiratory: Faint expiratory wheezes noted bilaterally, cleared after coughing.GI: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organo-megaly noted.GU: DeferredMusceloskeletal: Crepatus noted bil knees, no warmth or redness noted.Integrementary: Skin warm and dry, No rashes notedNeuro: Follows commands without difficultyWorking with your group, utilize the above case study a, develop a Voice Over PowerPoint presentation for your patient covering the problems identified in the case study and content in Unit 3 of Edelman, Kudzama, & Mandle (2018). Include the following:2-Health Education3-Complementary and Alternative Strategies

 

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