Need health and medical help with an Endocrine case study
Endocrine case study
CC/PMI: GB is a 65 year-old male who comes in for a check-up on the request
of his spouse. His last check-up was 10 years ago. He has no complaints other
than some leg numbness and tingling from time-to-time and feeling thirsty and
tired most of the time.
SH: no smoking or alcohol consumption
Physical Examination:GEN: well-nourished, slightly obese
male
VS: BP 170/100, Hr 70, RR 12, T 98.7, Wt 89kg, Ht 5’8″
HEENT:
PERRLA
COR: RRR, NMRG
CHEST: CTA
NEURO: monofilament test shows
decreased peripheral sensation
EXT: normal
Laboratory (fasting):
|
Na 140 |
Cl 100 |
BUN 32 |
BG 250 |
|
K 3.7 |
HCO3 24 |
SCr 1.9 |
|
|
ALT 35 |
AST 40 |
Alb 4.0 |
|
|
Ca 9.0 |
TP 7 |
Cholesterol 250 |
UA: SG 1.012, pH 6.4, +++ protein
Questions
- What major problems can you identify with this patient?
- What is your assessment and plan for each problem?
- Provide pharmacological and nonpharmacological care (don’t forget to be
specific). Will you add any new medications? - How will you monitor each problem and each medication included in your plan?
- When will you suggest following up with the patient?
- Is there any laboratory monitoring that will need to be conducted to assure
the safety of the patient?
