Using the I Can PresCribe A Drug Template (found in the resources section) please formulate a treatment plan for this case study patient. Please review the Case Study Rubric in the resources sec
Using the I Can PresCribe A Drug Template (found in the resources section) please formulate a treatment plan for this case study patient. Please review the Case Study Rubric in the resources section before completing this case study. **In addition to completing the template, please add any lab testing and health promotion/preventative activities you would suggest for the patient, considering his gender, age, and history. Case Study #1 Ronald James Chief Complaint: “I have been having stomach pain on and off since I started taking a medication for gout.” History of Present Illness (HPI): Ronald James is a 65 year old patient who was seen at an urgent care 3 weeks ago. He was diagnosed with acute gout and was prescribed Naproxen sodium 220 mg twice daily. He reports today his right great toe pain has resolved and he has stopped the medication. He has been taking Rolaids regularly with some relief of pain. He presents today for re-evaluation of his gout symptoms along with “stomach pain” for 3 weeks. PMH: Hypertension Type II Diabetes Acute Gout PSH: No surgeries Social History: Married for 40 years, 3 adult children all well Father deceased at 54 years from myocardial infarction Mother alive age 85 years, has Type II DM, hypertension Siblings: one brother with hypertension, heart disease NKDA Medication List: Amlodipine 5 mg/daily Lisinopril 20 mg/daily Metformin 500 mg twice/daily Multi-vitamin Review of Systems (ROS) General: no change in weight HEENT: denies sore throat Heart: denies exertional chest pain, palpitations Lungs: no cough GI: positive for heartburn that is worse when lying down and has awakened him from his sleep a couple times weekly. Normal BMs usually once/day, no blood in stool GU: no urinary issues, no nocturia Extremities: no edema, no joint deformities, swelling, or pain Neuro: mild peripheral neuropathy Vitals: BP 124/72, pulse 74 & regular, RR 18, Temp. 97.8; Height 71 inches, weight 210 lbs. Physical Exam: General: Alert & oriented X 3, no distress, appears stated age HEENT: sclera non-icteric, mucous membranes moist, throat without inflammation Neck: supple without lymphadenopathy, lymphadenopathy, no bruits Heart: regular rate and rhythm, S1 and S2 normal, no murmurs, rubs, or gallops Lungs: clear to auscultation Abdomen: soft, nontender, nondistended, bowel sounds normoactive, no hepatosplenomegaly, no guarding, rigidity, or rebound; mild epigastric pain on palpation Extremities: no edema, monofilament shows patchy neuropathy to feet bilaterally Neuro: grossly intact
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