see attachment files (1)week5-discussion….docxweek5-discussion….docx
INITIAL VISIT NOTES:
SUBJECTIVE:
Maxwell is a 40 – year – old homosexual African – American male and corporate lawyer who has been our patient for the last three years. At that time, he had not been to a primary care provider since graduating from law school. The patient admitted to a sedentary lifestyle, a weight gain of 25 pounds within the past two years, and occasional fatigue and headache.
Past medical history: None significant.
Past surgical history: Significant for a tonsillectomy at the age of 7.
Family history: Significant for thyroid disease, hypertension, type 2 diabetes, hyperlipidemia, and obesity.
OBJECTIVE:
Vital s signs: 220 pounds with a height of 6 ft 1 inch and a body mass index of 29. Blood pressure: 140/88; radial pulse: 78; temperature: 98.7; and respiratory rate: 16.
Physical examination: Significant for acanthosis nigricans and central adiposity.
Diagnostic test results: Fasting lipids revealed total cholesterol of 182, a low-density lipoprotein level of 106, a high-density lipoprotein level of 57, and a triglyceride level of 95. His fasting blood glucose was 95, and his A1c was 5.6. His thyroid-stimulating hormone level was 0.24. A routine electrocardiogram documented normal sinus rhythm and rate.
Diagnoses: Stage 1 hypertension (due to the elevation of blood pressure) and hypothyroid disease (since the thyroid stimulating hormone level was abnormally low).
Plan: The patient was started on both hydrochlorothiazide 25 mg by mouth daily and levothyroxine 0.25 mcg by mouth daily. He was counseled regarding lifestyle modifications, including preparing and eating a low-sodium and low-fat diet. Maxwell was encouraged to start a routine exercise program of at least 30 minutes of modest aerobic activity, such as walking as if to catch a bus. He was also encouraged to lose 5% ?? 7% of his body weight. These lifestyle modifications have proven effective in diabetes prevention and maintenance and control of blood pressure and lipid levels. The patient was informed regarding the mechanism of action of both medications, duration of action, contraindications, and adverse effects. The patient was also instructed to take levothyroxine on an empty stomach first thing in the morning.
THREE – MONTH FOLLOW – UP VISIT
THREE-MONTH FOLLOW UP VISIT NOTES:
Vital signs: Blood pressure of 128/76.
Diagnostic test results: Thyroid stimulating hormone level = 3.37. Basic metabolic panel: Blood urea nitrogen level of 14; creatinine level of 0.98; sodium level of 137; potassium level of 3.5; and chloride level of 104.
Plan: The patient was given a list of potassium-containing foods and reminded to eat 1 or 2 daily due to a low potassium level. He was instructed to continue to take the hydrochlorothiazide.
TWO YEARS LATER
RECENT VISIT (2 years later)
SUBJECTIVE:
Maxwell has been very busy climbing the corporate ladder and has not been in for a physical examination
or lab work for two years. He complains of extreme fatigue for the past two
months and low libido. He states that he always feels fatigued, and sleep does not seem to relieve
it. He can work but has limited socialization and participation in outside activities due to fatigue. He reports sleeping for 8 ?? 10 hours a night, with his sleep being interrupted by a need to go
to the bathroom at least twice. He awakens fatigued.
Sexually, he has a morning erection but not as strongly as in previous months. He has limited
sexual desire. He can have an erection with intercourse, but it is less of an erection than previously.
He states that he has been in a monogamous relationship for the past two years. He admits to a
15 – pound weight gain over the past two years. He reports that he experiences occasional constipation
and some cold intolerance. He denies fever, night sweats, and tobacco or drug use and reports socially
drinking several glasses of red wine per week.
Past medical history: Unchanged. / Past surgical history: Unchanged.
Family history: His father died recently from a heart attack.
Medications: Hydrochlorothiazide, 25 mg PO QD; levothyroxine, 0.50 mcg PO; multivitamin, one capsule PO QD; and fish oil capsules, 2000 mg PO QD. There are no known drug allergies or no known food allergies.
OBJECTIVE:
Vital signs: Temperature: 98.6; radial pulse: 76; blood pressure: 134/80; oxygen saturation: 99%; height: 6 ft 1 inch; weight: 235 lb (15 – lb weight gain); and body mass index: 31. Physical exam is unremarkable except for the following findings:
Skin: Poor skin turgor; acanthosis nigricans.
Mouth: Dry oral mucosa.
Abdomen: Central adiposity.
Lymph: No significant lymphadenopathy.
Rectal: Hemoccult negative for occult blood.
Based on the described case scenario, please answer two of the following questions:
1. -Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?
2. -What is the most likely differential diagnosis, and why?
3. -What is your plan of treatment?
4. -Are any referrals needed?
5. -Does the patient??s psychosocial history impact how you might treat this patient?
6. -What if the patient were over age 65?
7. -What if the patient was over the age of 80?
8. -Are there standardized guidelines that should be used to assess and treat this patient?
DQ Submission requirements:
· The submitted paper should be according to current APA7 guidelines.
· Must utilize credible data sources such as CINAHL, MEDLINE, Embase, Clinical Key, and Cochrane Library (Accessed from the library page at the fnu.edu website).
· FNU Librarians are available to assist each student with retrieving the required scholarly content.
· 2 or more scholarly sources must be utilized.
· All sources must have been published within the last five years.
· All article sources must be cited.
week5-discussion….docx
INITIAL VISIT NOTES:
SUBJECTIVE:
Maxwell is a 40 – year – old homosexual African – American male and corporate lawyer who has been our patient for the last three years. At that time, he had not been to a primary care provider since graduating from law school. The patient admitted to a sedentary lifestyle, a weight gain of 25 pounds within the past two years, and occasional fatigue and headache.
Past medical history: None significant.
Past surgical history: Significant for a tonsillectomy at the age of 7.
Family history: Significant for thyroid disease, hypertension, type 2 diabetes, hyperlipidemia, and obesity.
OBJECTIVE:
Vital s signs: 220 pounds with a height of 6 ft 1 inch and a body mass index of 29. Blood pressure: 140/88; radial pulse: 78; temperature: 98.7; and respiratory rate: 16.
Physical examination: Significant for acanthosis nigricans and central adiposity.
Diagnostic test results: Fasting lipids revealed total cholesterol of 182, a low-density lipoprotein level of 106, a high-density lipoprotein level of 57, and a triglyceride level of 95. His fasting blood glucose was 95, and his A1c was 5.6. His thyroid-stimulating hormone level was 0.24. A routine electrocardiogram documented normal sinus rhythm and rate.
Diagnoses: Stage 1 hypertension (due to the elevation of blood pressure) and hypothyroid disease (since the thyroid stimulating hormone level was abnormally low).
Plan: The patient was started on both hydrochlorothiazide 25 mg by mouth daily and levothyroxine 0.25 mcg by mouth daily. He was counseled regarding lifestyle modifications, including preparing and eating a low-sodium and low-fat diet. Maxwell was encouraged to start a routine exercise program of at least 30 minutes of modest aerobic activity, such as walking as if to catch a bus. He was also encouraged to lose 5% ?? 7% of his body weight. These lifestyle modifications have proven effective in diabetes prevention and maintenance and control of blood pressure and lipid levels. The patient was informed regarding the mechanism of action of both medications, duration of action, contraindications, and adverse effects. The patient was also instructed to take levothyroxine on an empty stomach first thing in the morning.
THREE – MONTH FOLLOW – UP VISIT
THREE-MONTH FOLLOW UP VISIT NOTES:
Vital signs: Blood pressure of 128/76.
Diagnostic test results: Thyroid stimulating hormone level = 3.37. Basic metabolic panel: Blood urea nitrogen level of 14; creatinine level of 0.98; sodium level of 137; potassium level of 3.5; and chloride level of 104.
Plan: The patient was given a list of potassium-containing foods and reminded to eat 1 or 2 daily due to a low potassium level. He was instructed to continue to take the hydrochlorothiazide.
TWO YEARS LATER
RECENT VISIT (2 years later)
SUBJECTIVE:
Maxwell has been very busy climbing the corporate ladder and has not been in for a physical examination
or lab work for two years. He complains of extreme fatigue for the past two
months and low libido. He states that he always feels fatigued, and sleep does not seem to relieve
it. He can work but has limited socialization and participation in outside activities due to fatigue. He reports sleeping for 8 ?? 10 hours a night, with his sleep being interrupted by a need to go
to the bathroom at least twice. He awakens fatigued.
Sexually, he has a morning erection but not as strongly as in previous months. He has limited
sexual desire. He can have an erection with intercourse, but it is less of an erection than previously.
He states that he has been in a monogamous relationship for the past two years. He admits to a
15 – pound weight gain over the past two years. He reports that he experiences occasional constipation
and some cold intolerance. He denies fever, night sweats, and tobacco or drug use and reports socially
drinking several glasses of red wine per week.
Past medical history: Unchanged. / Past surgical history: Unchanged.
Family history: His father died recently from a heart attack.
Medications: Hydrochlorothiazide, 25 mg PO QD; levothyroxine, 0.50 mcg PO; multivitamin, one capsule PO QD; and fish oil capsules, 2000 mg PO QD. There are no known drug allergies or no known food allergies.
OBJECTIVE:
Vital signs: Temperature: 98.6; radial pulse: 76; blood pressure: 134/80; oxygen saturation: 99%; height: 6 ft 1 inch; weight: 235 lb (15 – lb weight gain); and body mass index: 31. Physical exam is unremarkable except for the following findings:
Skin: Poor skin turgor; acanthosis nigricans.
Mouth: Dry oral mucosa.
Abdomen: Central adiposity.
Lymph: No significant lymphadenopathy.
Rectal: Hemoccult negative for occult blood.
Based on the described case scenario, please answer two of the following questions:
1. -Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?
2. -What is the most likely differential diagnosis, and why?
3. -What is your plan of treatment?
4. -Are any referrals needed?
5. -Does the patient??s psychosocial history impact how you might treat this patient?
6. -What if the patient were over age 65?
7. -What if the patient was over the age of 80?
8. -Are there standardized guidelines that should be used to assess and treat this patient?
DQ Submission requirements:
· The submitted paper should be according to current APA7 guidelines.
· Must utilize credible data sources such as CINAHL, MEDLINE, Embase, Clinical Key, and Cochrane Library (Accessed from the library page at the fnu.edu website).
· FNU Librarians are available to assist each student with retrieving the required scholarly content.
· 2 or more scholarly sources must be utilized.
· All sources must have been published within the last five years.
· All article sources must be cited.
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