Primary Care of the Maturing and Aged Family Case Study

Chamberlain College of Nursing

Patient Case Study 

AJS is a 58-year-old Pacific Islander, male, who presents with numbness & tingling in his feet for the past 6 weeks. He shows you a small cut on his right index finger that happened when he was pruning the bushes in the front yard 3 months ago. He states his stomach feels bloated after every meal and he is having a hard time concentrating at work. No exercise for the past 6 months. 

EKG ordered.

Current medications: OTC Pepcid 40mg daily, Vitamin D drops, Tapazole 5mg daily

PMH: Hyperthyroidism, history of heavy ETOH use, quit drinking about 6 months ago, no tobacco, occasionally smokes marijuana

FH: father CVA last year, mother Type II DM, sister/CAD, brother/heavy ETOH, Type II DM.

SH: Truck driver, divorced 2 times, currently married, 2 sons first marriage, no known health issues, 

Allergies: Shellfish, peanuts

Vital signs: BP 172/100; pulse 90, regular; respiration 20, regular Height 510, weight 275 pounds 

General: obese male, alert, oriented and cooperative. Skin: warm dry and intact. Open Cut Right Index finger, No retinopathy. There is no clinical evidence of congestive heart failure or peripheral vascular disease.

HEENT: head normocephalic. Bald. Eyes without exudate, sclera white. Readers. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, palpable goiter.

CV: S1 and S2 RRR without rubs or murmurs. 

Lungs: Clear to auscultation bilaterally, respirations unlabored. 

Abdomen: large rounded, soft, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. 

Laboratory Values:

CBC: 

Hgb 12.5 gm/dl 

Hct 41% 

RBC 4.3 million

WBC 4,800/mm3 

 MCV 87 fl 

MCHC 34 g/dl 

RDW 13.8% 

Thyroid – 

TSH: 4.2 

Free T 1.9

CMP: Sodium 138, Potassium 4.8, Chloride 100, CO2 29, Glucose 94, BUN 14, Creatinine 1.0

Calcium 9.5, Total protein 7.6, Bilirubin: total 0.8, Alkaline phosphatase 72 

AST 28, ALT 32, Anion gap 8.10, Bun/Creatinine 16.8

Hemoglobin A1C: 11.9 % 

I have uploaded the files for the rubric and instructions to review. Patient must have diagnostics, presribed meds, referrals, and follow ups.