10_Prescription Skill 4.pptx
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This document contains four patient case summaries: 1) A 25-year-old male farmer presented with blood in stool, abdominal pain, and weakness. Examination found pallor and urticarial rash. Stool examination found eggs of Anchyostoma duodenale indicating hookworm infection. 2) A 55-year-old woman presented with unintentional weight loss, weakness, and increased appetite without family history of diabetes or other conditions. Blood tests found prediabetes. 3) A 55-year-old woman was admitted with severe vomiting and altered mental status after irregularly taking higher doses of metformin. Tests found diabetic ketoacidosis. 4) A 68-
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1. Several patients presented with various respiratory complaints. Case 1 had shortness of breath and seizures, and CT showed pulmonary embolism. Case 2 had cough and shortness of breath, and CT showed bilateral bronchiectasis possibly related to allergic bronchopulmonary aspergillosis. Case 3 had abdominal distension, shortness of breath, and decreased urine output, and CT showed pulmonary embolism in a patient with known liver adenocarcinoma and ascites. Case 4 had cough and fever and CT showed a left upper lobe lesion possibly related to pulmonary tuberculosis.
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1 A 45-year-old male comes to the clinic with a chief complaint.docx
1 A 45-year-old male comes to the clinic with a chief complaint
QUESTION 1 A 45-year-old male comes to the clinic with a chief complaint of epigastric abdominal pain that has persisted for 2 weeks. He describes the pain as burning, non-radiating and is worse after meals. Also, he denies nausea, vomiting, weight loss or obvious bleeding. Finally, he admits to bloating and frequent belching.
PMH-+ for osteoarthritis, seasonal allergies with frequent sinusitis infections.
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Family Hx-non contributary
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1 of 2 Questions:
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2 of 2 Questions:How do these factors contribute to the formation of peptic ulcers?
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PMH-HTN, venous stasis ulcers, irritable bowel syndrome, osteoarthritis of knees, morbid obesity (BMI 48 kg/m2)
Family history-non contributary
Medications-amlodipine 10 mg po qd, dicyclomine 20 mg po, ibuprofen 600 mg po q 6 hr prn
Social hx- 15 pack/year history of smoking, occasional alcohol use, denies vaping
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Week 2: Respiratory Clinical Case
Patient Setting:
65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing, shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today.
HPI
Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy.
PMH
History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year.
Past Surgical History
None
Family/Social History
Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF
Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.
Medication History
Theophylline SR Capsules 300 mg PO BID
Albuterol inhaler, PRN
Phenytoin SR capsules 300 mg PO QHS
HTCZ 50 mg PO BID
Enalapril 5 mg PO BID
Allergies
NKDA
ROS
Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache, swelling in the extremities and seizures.
Physical exam
BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”
VS after Albuterol breathing treatment - BP 134/79, HR 80, RR 18
Gen: Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses. NEURO: A&O X3, cranial nerves intact.
Laboratory and Diagnostic Testing
Na - 134
K - 4.9
Cl - 100
BUN - 21
Cr - 1.2
Glu – 110
ALT – 24
AST - 27
Total Chol – 190
CBC - WNL
Theophylline - 6.2
Phenytoin - 17
Chest Xray – Blunting of the right and left costophrenic angles
Peak Flow – 75/min; after albuterol – 102/min
FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%
Week
2
:
Respiratory
Clinical Case
Patient Setting:
65
year old
Caucasian female
that was
discharged from the
hospital
10 weeks ago
after
a
motor vehicle
accident presents to the clinic today.
States she is having severe wheezing, shortness of breath and
coughing at least once daily. She can barely get her words out
without taking breaks to catch her breath
and states she has taken albuterol once today.
HPI
Frequent asthma attacks for the past 2 months
(more than 4 times per week
average
)
, serious MVA 10
weeks ago; post traumatic seizure 2 w
eeks after the accident; anticonvulsant phenytoin started
–
no
seizure activ.
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Week 2 Respiratory Clinical CasePatient Setting65 year old C.docx
Week 2: Respiratory Clinical Case
Patient Setting:
65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing, shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today.
HPI
Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy.
PMH
History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year.
Past Surgical History
None
Family/Social History
Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF
Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.
Medication History
Theophylline SR Capsules 300 mg PO BID
Albuterol inhaler, PRN
Phenytoin SR capsules 300 mg PO QHS
HTCZ 50 mg PO BID
Enalapril 5 mg PO BID
Allergies
NKDA
ROS
Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache, swelling in the extremities and seizures.
Physical exam
BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”
VS after Albuterol breathing treatment - BP 134/79, HR 80, RR 18
Gen: Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses. NEURO: A&O X3, cranial nerves intact.
Laboratory and Diagnostic Testing
Na - 134
K - 4.9
Cl - 100
BUN - 21
Cr - 1.2
Glu – 110
ALT – 24
AST - 27
Total Chol – 190
CBC - WNL
Theophylline - 6.2
Phenytoin - 17
Chest Xray – Blunting of the right and left costophrenic angles
Peak Flow – 75/min; after albuterol – 102/min
FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%
Week
2
:
Respiratory
Clinical Case
Patient Setting:
65
year old
Caucasian female
that was
discharged from the
hospital
10 weeks ago
after
a
motor vehicle
accident presents to the clinic today.
States she is having severe wheezing, shortness of breath and
coughing at least once daily. She can barely get her words out
without taking breaks to catch her breath
and states she has taken albuterol once today.
HPI
Frequent asthma attacks for the past 2 months
(more than 4 times per week
average
)
, serious MVA 10
weeks ago; post traumatic seizure 2 w
eeks after the accident; anticonvulsant phenytoin started
–
no
seizure activ.
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