Case 1 A 50-year-old man comes to your office for a routine…
Question Case 1 A 50-year-old man comes to your office for a routine… Case 1A 50-year-old man comes to your office for a routine physical examination. He is a new patient to your practice. He states his father died at the age of 73 of a heart attack. His mother is alive at the age of 80. He has hypertension, which he takes chlorthalidone 25 mg PO daily. Takes Tylenol as needed for pain. Denies seasonal or drug allergies. He has two younger siblings with no known chronic medical conditions. Last eye and dental exam two years ago. He is married in a monogamous relationship without children. Has a high school diploma. Works full-time for local landscaping business. He does not smoke, drink alcohol, use any recreational drugs and does not exercise. He denies fever, chills, weight loss or weight gain. He denies hearing changes, headaches, or dizziness. He reports some visual changes when reading close-up. He denies shortness of breath, dyspnea on exertion, swelling or chest pain. He reports increase urination and thirst. Denies abdominal pain, nausea, vomiting or changes in appetite. He reports daily BM. Denies rashes or bug bites. Uses sunscreen daily due to working outside. Denies anxiety or depression. On examination his blood pressure is 126/82, pulse is 80 beats/min, respiratory rate is 18. Height is 67 inches and weight is 190lbs. Does not appear in acute distress, responses are appropriate and appears reliable source. Alert, oriented to person, place, time and situation. Well-nourished, skin warm, dry and intact. Normocephalic. Pupils size 3 mm, equal and reactive to light. Extraocular eye movements intact to six directions. Tympanic membranes gray with adequate cone of light bilaterally. Mucous membranes pink and moist. No palpable masses, thyromegaly, lymphadenopathy or JVD. Regular heart rate and rhythm, S1 and S2. No bruits auscultated. Capillary refill less than 3 seconds. Breath sounds clear bilaterally to auscultation. No use of accessory muscles or purse lip-breathing. Soft, non-tender, non-distended, normoactive bowel sound. No organomegaly or guarding. Denies numbness or tingling. He reports he has not had HIV or PSA screenings. Health Science Science Nursing NU 610 Share QuestionEmailCopy link Comments (0)
