Patient Joe Smith, a 78-year-old, accompanied by his son, is being seen in the office. Assisted into exam room with son because of unsteady gait.

 

Patient

Joe Smith, a 78-year-old, accompanied by his son, is being seen in the office. Assisted into exam room with son because of unsteady gait. Patient states he has been having “trouble remembering things.” He has been having trouble sleeping at night. Also, mention he has increased frequency of urination especially at night. Son states his father recently fell in bathroom.

Social hx

• Lives alone in his own home

• Widower (wife died suddenly 1 month ago after 60 years of marriage)

• Does not smoke or drink alcohol

 

Past Surgeries

• Angioplasty with coronary stent x 3 (2012)

 

PMH

• Hypertension, CAD

 

Current meds

• Lisinopril 20mg daily

• Atrovastatin 20 mg daily

• Plavix 75 mg daily

• Furosemide 20mg daily prn

• ASA 81 mg daily

• Tylenol pm

• Neurontin 300mg tid

• Amitriptyline 25 mg (recently started by neurologist for neuropathy in feet)

 

P.E.

• Ht 6’0′ ; Wt 170 lbs; BP sitting 138/82;BP standing 136/80; P 60, R 16. T 97.1

• Alert and oriented x 3 however easily distracted

• PERRLA, EOM intact, sclera clear and white

• Speech clear in context and clarity

• No lymphadenopathy noted

• HR-RRR

• Lungs CTA

• Muscle strength full proximally and distally

• No edema noted in bilateral lower extremities

• No discharge noted from uncircumcised penis

MVU MSN623

• Digital rectal exam enlarged prostate smooth in texture, no tenderness with palpation

 

Labs

You have results from 1 day ago when son took patient to urgent care.

• UA: color clear, specific gravity 1.055, pH 7.4, negative for proteins, ketones, RBC; trace bacteria

• CMP: BUN 8, Na 134, K+ 2.8, Mg 0.7mg/dl, Cr 1.0

• CBC w/differential- all within normal limits

 

Questions

1. What further questions do you want to ask your patient?

2. What diagnostics would you consider today?

3. What are your differential diagnoses? Name 3.

4. What is your diagnosis today?

5. What is your treatment plan, including medications, patient education, and guidelines for patient to call your office and a return office visit