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Homework answers / question archive / Patient Presentation: Primary care practice Chief Complaint: “I’ve been feeling really tired over the last few weeks and I haven’t felt like doing anything or going anywhere

Patient Presentation: Primary care practice Chief Complaint: “I’ve been feeling really tired over the last few weeks and I haven’t felt like doing anything or going anywhere

Nursing

Patient Presentation: Primary care practice

Chief Complaint: “I’ve been feeling really tired over the last few weeks and I haven’t felt like doing anything or going anywhere. On top of that, yesterday, I started feeling burning when I tried to urinate, but I don’t think I’m fully emptying my bladder. It’s getting really uncomfortable.  I just want to enjoy the summer.”

History of Present Illness: MA is a 68 year-old AA female with PMH significant for hypothyroidism, CAD s/p PCI with 2 stents to LAD (2015), and CKD3 who presented with complaints of fatigue over the last week with new urinary symptoms including burning and retention. She reports she is overdue for her annual physical and lab work because she spent the winter in Arizona, but reports her BP has been controlled measuring 110/70s.

Today’s visit type: Urinary tract infection

Past Medical History:  Hypothyroidism, CAD s/p PCI (2015), HTN, CKD3

Allergies: amoxicillin (rash)

Medications: Levothyroxine 75 mcg daily, aspirin 81 mg daily, atorvastatin 10 mg daily, losartan 100 mg daily, carvedilol 6.25 mg BID

Immunizations: Influenza (October 2020), Tdap (September 2009), Shingrix (November 2019)

Family History:

•             Father: Died of heart attack in his 50s

•             Mother: HTN, MDD

•             Sister: HTN

•             Brother: HTN, diabetes

Social History:

•             Occupation: Retired librarian. Planning on volunteering when the library summer programs begin.

•             Substances: Occasional margarita on her porch, denies tobacco or illicit substances

•             Sexual: Sexually active with husband

•             Insurance: Medicare D – Johns Hopkins Med Adv HMO

Review of Systems:

HEENT: no vision changes, no ear pain/pressure/fullness, no sore throat

Neuro: no headaches

CV: no chest pain, no palpitations, no edema

Resp: no cough, no SOB, no DOE

GI: no nausea, no vomiting, no diarrhea

GU: burning and retention during urination

 

Physical Exam:

•             General: Comfortable, non-toxic

•             Vitals: BP 120/65, HR 82, RR 20, Temp 37.1 C, O2 sat 98% on room air

•             Height: 5’9”       Weight: 88 kg

•             Neuro: alert and oriented x 3

•             HEENT: dry mucus membranes

•             CV: regular rate and rhythm, no murmurs, rubs, or gallops

•             Resp: lung sounds are clear in all lobes bilaterally without rales, ronchi, or wheezes

•             GI: soft, nondistended abdomen, normoactive bowel sounds, no discomfort in suprapubic region

•             GU: normal pelvic exam

•             Skin: skin warm, dry and intact without rashes or lesions

 

Pertinent labs:

SCr 1.7 (baseline 1.3)

eGFR 35

K 5.4

A1c 5.7%

TSH 18

T4 0.5

Total cholesterol 220

HDL 35

LDL 90

 

Urine studies:

(+) Nitrates

(+) Leukocyte esterase

Epi: 0

WBC: >10 WBC/hpf

 

Today’s acute diagnosis: Uncomplicated UTI

 

Please complete steps A, B, and C:

A.            Answer the following questions: (15 points)

1)            What signs and symptoms is the patient experiencing that indicates she has a urinary tract infection? What objective data supports a UTI?

2)            What is the difference between a complicated and non-complicated UTI?

3)            What are the first-line treatment options for an adult patient with an uncomplicated UTI? What factors from this patient’s case influence which antibiotic you will prescribe?

4)            What preventative medicine screenings and follow-up is needed for this patient?

5)            What is this patient’s baseline CrCl? What drug(s) on the home medication list may require adjustment for poor renal function or acute kidney injury?

 

B.            Complete the table below for this patient (add or delete rows as needed) (65 points)

Medical Problem           

 

List ALL current medical problems            Current Drug Regimen                       

 

For each problem list the current therapy. If none then write “none currently”  Therapeutic Goals (e.g., desired endpoints)

 

List your goals for each of the identified problems – Be specific!                Therapeutic recommendations.

 

List your recommendations for pharmacologic management      

Monitoring

 

Describe monitoring needed to determine efficacy and safety of therapies

 

                Rationale

 

Explain why you made the choices you made used patient-specific and evidence-based support wherever possible

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

 

C.            Patient education – please provide disease and medication-specific (for ALL medications prescribed) patient education that should be shared with this patient (10 points)

 

D.            Write a prescription for EVERY medication that is prescribed. This includes medications she was previously prescribed that you plan to continue [if any], as well as any new medications you plan to initiate including OTC medications. Use the prescription template form attached in the assignment. Please do not put more than one medication on each prescription form. Also, patient education is listed above and is not generally included on a prescription (there is no room for this on the bottle label). (10 points)

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