Primary Care: A Collaborative Practice
Terry Mahan Buttaro & JoAnn Trybulski & Patricia Polgar-B..
Post a response to the case study applying your new learning from Parts 8 – 13. Then analyze and respond to two other students post.
Case Study II
James Green is a 58-year-old coalminer who presents to your clinic with complaint of runny congested nose, sore throat with a persistent cough and fever for one week. He also advises that his blood pressure has been elevated and he has felt some palpitations off and on during this time. Furthermore, he advises that he has been having some nonspecific right upper quadrant abdominal pain with nausea and vomiting. He denies any other family members are ill.
Height: 6 feet 2 inches
Weight: 205 pounds
PMHX: COPD, pneumonia, coronary artery disease, hypertension, pancreatitis, and renal failure, testicular cancer
PSHX: Left testicular orchiectomy secondary to cancer, cholecystectomy, renal calculi
PFMHX: Diabetes, hypertension, colon cancer, prostate cancer, COPD, CAD
Tobacco: stop smoking 15 years ago, advised smoked one pack a day for 20 years
Alcohol, drinks an occasional beer on the weekends when watching football
Illicit drugs: denies any illicit drugs
Vital signs: B/P 178/112, pulse 118, Resp 26, Temp 96.8 oxygen saturation 89% on room air
– Summarize what the patient has told you
– Categorize what you have been told and placed them in the order of priority
– Formulate appropriate differential diagnoses using pathophysiology to substantiate your reasoning (decision making process)
– Make a list of working diagnosis and list your treatment plan
– List any possible resources and patient education that should be used
– Develop a management/treatment plan including follow-up