Client
Jose is a 47 year old morbidly obese Latino male who presents to the clinic for follow up evaluation of headaches, dizziness, ringing in his ears and frequent urination. He reports having a headache that “comes and goes” with ringing in his ears and sometimes he sees spots. Jose has taken acetaminophen and states that seems to help. Due to his work schedule of six 12 hour days, Jose has not had preventive care. He reports fatigue and is depressed regarding his current income situation. Jose has just been laid off for the season and will lose his insurance in 30 days until the restart of the harvesting season in March. He is concerned about paying for any health care that may go beyond his benefit period. Jose lives with his pregnant wife, who does not work, and their seven children in a three bedroom one bath house that they share with his parents and his brother’s family of three.
Review of Systems Subjective Data
General: occasional fatigue, gradual weight gain over the past ten years
HEENT: (+) visual and hearing changes with HA; (-) cold or recent upper respiratory
changes, (-) rhinorrhea or nose bleeds,
Cardiac: (-) chest pain or tightness, no palpitations
Respiratory: no asthma, (+) snores at night
GI: (-) pain, nausea, vomiting, constipation, visible fecal blood, (+) GERD, reports occasional indigestion after meals,
GU: (+) frequent urinary for 1 month with increased thirst
MS: (+) chronic bilateral shoulder and low back pain for 7+/- years, takes ibuprofen prn.
Neuro: (+) headaches 2- 3 times a week relieved with acetaminophen, (+) dizziness, sees spots with HA which are not related to activity, (-) weakness, (+) numbness and tingling in both feet,
(-) changes in speech or memory
Skin: (-) rashes or lesions
Allergies (-)
Psych: (+) Depressed about income, wife is unable to work and is pregnant
7 children ages 2 years-13 years.
Past Medical History: Denies problems No preventative care. Only acute care for cold or flu.
Past Surgical History: None
Medications: None
Social History: (-) substance abuse, (+) ETOH, drinks 1-2 beers a day and 5-6 beers on the weekend with family on Saturday and Sunday. Drinks 2 cups of coffee with cream and sugar in the AM, does not exercise except working in the fields picking broccoli, likes to watch TV at night, eats a high carbohydrate diet of rice, beans, potatoes, corn and tortillas (8-10 a day) eats at home, does not eat out often. Drinks water, no sodas or junk food. Reports drinking freshly made jimaca (hibiscus) tea with sugar and fresh cucumber lime drink with sugar three times a week. Rarely eats deserts.
Family History: Parents and siblings all living. 2 brothers and 3 sisters. (+) hypertension – father and mother, 2 brothers and 2 sisters (+) diabetes-father, mother, 1 brother and 1sister, (+) coronary heart disease- father, mother, 1 brother, (+) hypercholesterolemia- father, mother, 1 brother, 2 sisters
Physical Examination – Objective Findings
Ht. 64 inches Wt. 294 lbs. BP 176/104 mmHg HR: 92 RR: 24 T: 98.8 F
General: Well appearing, well groomed, NAD, looks stated age, morbidly obese
Eyes: PERRLA, Fundoscopy with no AV nicking or copper or silver appearance, no
papilledema, EOMI
Neck: supple, (-) lymphadenopathy, (-) thyromegaly,
CV/Heart: RRR, (-) murmur, rubs or gallops, lifts or heaves, tenderness to palpate, (-) carotid bruits, (-) pedal edema
Lungs: CTA bilaterally, respirations equal and unlabored
Abdomen: (+) BS x 4, soft, round, non-tender, (-) masses, organomegaly, bruits
MS: (+) steady gait, FROM all EXT, no cyanosis, clubbing, pedal pulses present, feet warm, monofilament test abnormal at R great toe, 2+ patellar DTR,
Neuro: CN 2-12 grossly intact, (-) Rhomberg, (-) Pronator drift, (-) Dix Hallpike
Skin: (-) rashes or lesions, color even WNL, hair normal distribution
Psych: appears anxious
Previous Lab and Diagnostic Testing: None available. Reports labs done in Mexico 10 years ago, does not remember results.
Current Lab Test Results – Fasted 12 hours – completed 1 week prior to clinic
appointment
Complete Blood Count/ Basic Metabolic Panel
WBC 5.0
RBC 4.8
Hgb 14
HCT 45.2
MCV 78
MCH 27
Glucose 238
Creatinine 0.6 mg/dl
Carbon dioxide 25 mEq/L
Chloride 100 mEq/L
Potassium 4.0 mEq/L
Sodium 142 mg/dl
Calcium 9 mg/dl
BUN 16 mg/dl
AST 68
ALT 82
Triglycerides 457
Cholesterol 368
LDL 325
HDL 38
Vit D 16
A1c 10.9
TSH 4.95
CRP 6
UA
Clear, pale yellow
pH 5.4
Specific gravity 1.021
Protein negative
Glucose 500++
Ketones Neg
Blood Neg
Cardiology/Endocrine Case Study
Answer the questions below using current national clinical practice guidelines, your pharmacology course textbook, previous pathophysiology coursework, and other sources such as journal articles to support your answers. Please review the grading rubric that will be used to evaluate your submission (100 points = 20% of total grade)
- Based on the patient’s labs and the Subjective and Objective data, what are the patient’s diagnoses? (Hint: There are at least 8.)
- Briefly discuss the pathophysiology of the top three diagnoses.
- Discuss the guidelines for diabetes management. What is the best drug(s) of choice for this patient? What are the benefits of the drug(s) for this patient? Explain the pharmacological action of the drug(s). Explain the importance of aspirin in diabetes. Describe how these medications work to stabilize and provide optimum health.
- Discuss the JNC 8 guidelines for hypertension management. What is the best drug(s) of choice for this patient? What are the benefits of the drug(s) for this patient? Explain the pharmacological action of the drug(s). Describe how these medications work to stabilize and provide optimum health.
- Discuss the AACE 2017 guidelines for dyslipidemia management. What is the best drug(s) of choice for this patient? What are the benefits of the drug(s) for this patient? Explain the pharmacological action of the drug(s). Describe how these medications work to stabilize and provide optimum health.
- Discuss non-pharmacological interventions to assist Jose in reaching his optimal health. This includes supplements/alternative/integrative medicine….
- List factors that increase the patient’s risk for cardiovascular disease (including labs).
Calculate Jose’s 10 year atherosclerotic cardiovascular disease (ASCVD) risk using the Framingham and Mesa calculators. - Discuss consequences of obesity as the one major cause of this patient’s problems that if corrected can impact all of his diagnoses. Explain how the related factors of his lifestyle affect his diagnoses. What type of diet is recommended according to the latest research? Is Jose a candidate for bariatric surgery and how does bariatric surgery help?
- Jose has expressed his inability to afford all of the medications he needs. What medication is required and how can his other diagnoses be treated? List other disciplines that could provide a multidisciplinary team approach to assist Jose in reaching optimal health.