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 cant 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, NKDA
Current medications: Pepcid OTC as needed
PMH: GERD,
PSH: Tonsillectomy, appendectomy
Social: Tobacco: 1 PPD, Alcohol: 2-3 drinks every 3-4 days, Denies illegal drug use. He works fulltime at Lowes, 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: unsure
Family: Father: died at 72 of MI, Mother: died at 60 of breast cancer
ROS:
Constitional:
HEENT: Denies any headache, nasal congestion, ear pain
Cardiovascular: Denies chest pain
Respiratory: Denies any SOB, DOE, orthnopenia
GI: Reports some burning pain at times, feels like heartburn.
GU: Denies any painful urination, urgency, hesitancy
Musculoskeletal: Reports some knee pain with bending, walking long distances. Denies any swelling or redness
Neurological: Denies
Psychiatric: Denies suidicial ideations, depression. Does report difficulty falling asleep
Endocrine: Reports he has lost about 10 pounds over the last few months.
Hematologic/ Lymphatic: Denies any bruising
OBJECTIVE:
Vital signs: Ht: 70, Wt: 265, BP 178/94, HR 92, Resp: 16, SaO2: 95%
Constitutional: Well developed, obese male
HEENT: 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 masses
Cardiovascular: RRR, No murmurs or rubs noted. No peripheral edema noted
Respiratory: 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: Deferred
Musceloskeletal: Crepatus noted bil knees, no warmth or redness noted.
Integrementary: Skin warm and dry, No rashes noted
Neuro: Follows commands without difficulty
Working 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 Education
3-Complementary and Alternative Strategies
