Paper instructions:
Case Study
Samuel J. is a 73-year-old male patient, who presents to you for his annual Medicare
Wellness physical with complaints of ongoing fatigue and insomnia.
At his visit today, Samuel has a weight gain of 15 pounds from the previous visit 6
months ago for a urinary tract infection. He also went to an urgent care clinic 4 months
ago and was diagnosed with another UTI, and was treated with antibiotics again. He
continues to have occasional nocturia but has no more dysuria, foul odor or other
urinary symptoms. He further expresses concerns over his nighttime insomnia, daytime
napping, slow weight gain, and growing lack of motivation to engage in his hobbies. He
is a Ham radio operator and is a member of a local club. He also plays tennis 1-2 times
a week, but states that he is sometimes short of breath when he plays tennis, especially
when it is quite cold. Sometimes his lower legs cramp when he plays tennis or climbs
stairs.
He has a part-time job at a local big box appliance and tech store which he formerly
enjoyed but now finds less so, even though his work friends are friendly. His wife of 45
years died about 18 months ago, and he is often lonely, although he has recently been
thinking about accepting the invitation of a widow in his neighborhood who keeps asking
him over for dinner. He grins when he says this, but says he is truly concerned that he is
not eating properly since his wife had done most of the grocery shopping and cooking,
and since her death he mostly eats microwave dinners that he knows are mostly full of
salt. His own father died at age 75 after complications of a stroke sustained at age 74,
and he does not want to end up the same way.
He has one daughter, son-in-law and 2 grandsons who lives about 10 miles away from
him and with whom he enjoys a close relationship. He has a military pension and Social
Security income and is covered by Medicare and Tricare supplemental insurance. His
home is easy to maintain and paid for, and his vehicle is paid for and in good condition.
Past medical history: Samuel was diagnosed with hypertension at age 42. He was
diagnosed with hypogonadism at age 55, BPH at age 65. Hernia surgery age 32 due to
military service in which he was a radio operator on a submarine.
Family medical history: Hypertension (both parents and siblings), stroke (father), and
diabetes (mother).
Social history: He lives alone, widowed, in a house in the inner city of a major
metropolitan area where air quality is often poor. He attends church regularly. Finances
stable, and most of his bills are covered by his Social Security and military retirement
income. His part time job supplements these sources of income. He is on Medicaid and
also has Tricare. Samuel smoked quite a bit for about 5 years during his early Navy
years, but he quit smoking when he his daughter was born. He now has an occasional
beer or whiskey with his other Navy buddies at the local bar. There is a good bit of
second hand smoke at this bar, and the air quality in his city is often poor. He is a Ham
radio operator and volunteers in emergency operations. He plays tennis at a local
community center once a week.
Medications: Furosemide 10mg PO QD; Lisinopril 20 mg QD, Rosuvastatin 20mg QD,
Tadalafil 5mg QD, Daily Aspirin 325mg, Daily Multivitamin, Daily Garlic tablet, Daily
Gingko (for memory).
Allergies: Penicillin.
Preventive Screenings: Colonoscopy age 60, last visit to urologist was age 65 for BPH
and placed on daily tadalafil (Cialis), EKG age 70, Chest x-ray age 70, Pulmonary
function test age 65, all wnl.
Immunizations: Flu shot: High dose Quadrivalent 3 years ago, PPSV23 age 64, Tdap
Age 57 when he had a gardening injury, Zostavax 1 dose age 60. He states Uncle Sam
gave him all kinds of shots when in the military but he is unsure of what these are.
OBJECTIVE
General: Cooperative, NAD.
Vital signs: BP: 142/86, P: 74, R: 18, O2=98% on Room air, Ht 511 Wt 218 (BMI
30.4) which is a weight gain of 15 pounds from the previous visit 6 months ago when
seen for a urinary tract infection
Labs:
Lipids: Total Cholesterol 204, HDL 48, LDL 139
BMP: (Fasting) Glucose 94, sodium (Na+) 140, potassium (K+) 4.0, chloride (Cl) 100,
CO2 22, blood urea nitrogen (BUN) 20, creatinine .98.
CBC: Hbg 10.1, Hct 35.6
Cardiovascular: Carotids +2; pulses without bruits. Regular rate and rhythm, S1 and
S2.
Respiratory: Lungs clear to auscultation.
Musculoskeletal: Full range of motion of the neck and arms.
Please use the information above to respond to the following in a scholarly, written
paper format.
1. List a minimum of six different diagnosis for your evaluation of Samuel today.
2. What are the pertinent positives for each diagnosis from his past medical history
and current labs and presenting symptoms?
3. What other items do you need to include in your physical assessment of
Samuel?
4. Is Samuels blood pressure considered in control for his age group at this point?
Provide reference for this.
5. Provide an analysis of Samuels lipid panel with rationale and next steps
including other lab tests. Provide reference for this.
6. Provide an analysis of Samuels hemoglobin and hematocrit with rationale and
differential diagnoses and next steps including lab and other diagnostic tests or
referrals. Provide reference for this.
7. Provide an analysis of Samuels urinalysis and next steps including lab tests and
other diagnostic tests or referrals, with rationale. Provide reference for this.
8. What immunizations should Samuel consider at this point?
9. According to the USPSTF, what preventive screening tests should be ordered for
Samuel? Provide rationale for this based on Samuels age, gender, and past
medical and social history.
10. What dietary guidance should be provided to Samuel?
11. Should you consider discussing sexual health with Samuel?
12. How should you evaluate Samuels insomnia and fatigue? What are your
differential diagnoses for this, provide rationales and references.
13. What depression screening should you provide for Samuel? Should you provide
Samuel with a referral to counseling at this point, explain why or why not.
14. Evaluate Samuels current medications and list your pharmacological
management for his hypertension, sleep, depression, and weight management.
15. Recommend your non-pharmacological management for Samuels hypertension,
sleep disorders, weight gain, and depression.
16. When should you schedule your next appointment with Samuel, what should you
and Samuel accomplish prior to that appointment and what will the goal of that
appointment be?
Your writing assignment should:
5 pages, not including the Title Page and Reference Pages
5-7 references
