Mr Jones, a 60 year old African American male, presents to the office for a planned 6
month follow up visit for hyperlipidemia and weight loss. At the previous visit, Mr Jones
was educated on lifestyle recommendations. He reports he has been following dietary
recommendations “as good as he could remember” and exercising as
recommended. He reports some new concerns today. He reports that he has been
experiencing increased fatigue for about the last 10 weeks. He has a health club
membership and attends 3-4 times a week. He walks on the treadmill at least 30
minutes as you directed and lifts weights but he has not lost any weight, in fact he has
gained 7 pounds. He doesn’t understand what he is doing wrong and is requesting more
education and suggestions for weight loss. He reports that exercise makes him even
more hungry and thirsty. He requests further evaluation for his fatigue. He reports he
has to go to the bathroom more often- he is waking up during the night to urinate and
seems to be urinating more frequently during the day. This has been occurring for about
2 months. No other GU symptoms such as painful urination, dribbling or changes in
sexual functionhave been noted.
Current medications: Simvastatin, 10 mg daily, Tylenol 500 mg 2 tabs in AM for knee
pain. Daily multivitamin and turmeric.
PMH: Hyperlipidemia. Right knee OA (for 2 years) Had chicken pox as a child.
Vaccinations up to date. Colonoscopy WNL 7 years- to repeat at 10 years
FH: parents deceased, child alive, well. No siblings.
SH: Divorced. Business executive, job requires frequent travel. Drinks 1-2 beers daily.
Former smoker, quit 5 years ago. No reports illicit drug use. No CBD use.
Allergies: allergic to Bactrim, strawberries, cats and pollen. No latex allergy
Vital signs: BP 119/77; pulse 80, regular; respiration 16, regular
Height 5’9.5”, weight 210 pounds
General: AA male in no acute distress. Alert, oriented and cooperative.
Skin: warm dry and intact. No lesions noted.
HEENT: head normocephalic. Hair thinning distribution across crown. Eyes without
exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light
reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx
moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior
and posterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid
midline, small and firm without palpable masses.
CV: S1 and S2 RRR without murmurs or rubs.
Lungs: Clear to auscultation bilaterally, respirations unlabored.
Abdomen- soft, round, nontender with positive bowel sounds present; no
organomegaly; no abdominal bruits. No CVAT.
Musculoskeletal: full ROM both knees. Nontender to palpation bilaterally. Gait normal.
GU: bladder nontender upon palpation.
Rectal: DRE: prostate not enlarged, rubbery texture, no nodules noted. Guaic negative
Labwork: (fasting labs drawn this morning)
CBC: WBC 6,300/mm3 Hgb 13.8 gm/dl Hct 42% RBC 4.6 million MCV 93 fl MCHC
34 g/dl RDW 13.8%
UA: pH 5, SpGr 1.006, Leukocyte esterase negative, nitrites negative, 1+ glucose;
negative protein; negative ketones
GFR est non-AA 99 mL/min/1.73
GFR est AA 101 mL/min/1.73
Total protein 7.6
Bilirubin, total 0.5
Alkaline phosphatase 72
Anion gap 8.10
Hemoglobin A1C: 6.9 %
TSH: 2.30, Free T 4 0.9 ng/dL
Cholesterol: TC 202 mg/dl, LDL 134 mg/dl; VLDL 36 mg/dl; HDL 32mg/dl, Triglycerides
EKG: normal sinus rhythm
The purpose of this case study assignment is to :
Activity Learning Outcomes
Through this assignment, the student will demonstrate the ability to:
Sunday 11:59 p.m. MT at the end of Week 5
This assignment is submitted through Turn It In (TII).* Students are allowed two opportunities to submit. The first Turn It In submission allows the student to view the Turn It In Score and edit the assignment if necessary. The second submission is considered the final submission and will be graded. Any further Turn IT In submissions will not be considered for grading.
*due to the amount of common case study content it is not unusual that the TII may exceed 25%. It is the original work, such as rationale statements and treatment plans that are evaluated for similarity by the faculty.
Total Points Possible: 160
The assignment is a paper, which is to be written in APA format using the provided assignment template. The paper shall not exceed 10 pages, excluding title page and references.
Review the provided patient visit information. You are provided with the subjective and objective exam findings. As the provider, you are to diagnose the case study patient and develop the management plan for this case study patient. Keep in mind this is a complex patient who has more than one diagnosis, which is common in primary care.
Use the provided case study template for your paper. Review the APA Manual to adhere to APA formatting.
Introduction: briefly discuss the purpose of this paper. (no more than 5 sentences)
Assessment: review the provided case study information.
Identify the primary and secondary diagnosis for the patient. Each diagnosis will include the following information:
Plan: (there are five (5) sections to the management plan)
Assessment of Comorbidities: in this section students will review the ADA Standards of Medical Care in Diabetes (the guidelines) Assessment of Comorbidities section on comorbidities subsection and choose one listed comorbidity. Students will discuss the significance of and the relationship between the patient’s primary diagnosis and the chosen comorbidity, explaining how one diagnosis affects the other diagnosis. Any recommended screening, diagnostic testing, and referrals are also included.
Medication costs: in this section students will research the costs of all prescribed and OTC monthly medications that you have prescribed and that the patient is currently taking that you would like to continue. Students may use Good Rx, Epocrates or another resource (students may use local pharmacy websites) which provides medication costs. Students will list each medication, the monthly cost of the medication and the reference source. Students will calculate the monthly cost of the case study patient’s prescribed and OTC medications and provide the total costs of the month’s medications. Reflect on the monthly cost of the medications prescribed. Discuss if prescriptions were adjusted due to cost. Discuss if will you use medication pricing resources in future practice
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