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Medical report - Case Study Example

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Patient and Setting: RJ is a 56-year-old white male who presents to his primary care physician.  Chief Complaint: Shortness of breath occurring with minimal exertion  History of Present Illness: RJ complains of increasing shortness of breath with minimal exertion…
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Medical report
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Medical report

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These resolved with courses of ciprofloxacin. Patient also reports chronic knee pain previously diagnosed as osteoarthritis. He uses acetaminophen for mild pain and ibuprofen with more significant pain and stiffness. He reports frequent symptoms of heartburn for which he uses Omeprazole intermittently. He has problems with insomnia since the death of this wife and uses Zolpidem occasionally (1-2 times per week).  Surgical History: Appendectomy at age 35  Family History: RJ is a widower who lives alone in a house that he owns. His wife died 3 years ago from lung cancer attributed to a 40 pack-year smoking history. One sister (age 63) is alive and has diabetes. Both parents are deceased. Father died in an automobile accident at age 68; mother died of breast cancer at age 54.  Social History: RJ has a 60 pack-year smoking history. He has smoked 1.5 to 2 packs per day for 35 years. He reports that he currently smokes 1 to 1.5 packs per day. Patient indicates that he has thought about stopping smoking but feels that there is too much stress right now for him to attempt it. He reports moderate alcohol use (glass of wine 3-4 times a week). He has one adult son (age 30) who is in good health and lives 2 hours away. Results of Pertinent Laboratory Tests, Serum Drug Concentrations, and Diagnostic Tests:
Note lab numbers in parentheses are listed to highlight that a lab value may be represented in different units. Numbers in parentheses should correspond with the adjacent number for a lab value. For example, please note normal BUN is 10a€“20 milligrams per deciliter (mg/dL) or 3.6-7.1 millimoles per liter (mmol/L)  Na (sodium)135  K (potassium) 4  Cl (chloride)104  HCO3 23  Glucose 6.6 (119) BUN 4.6 (13)  Cr (Creatinine)123.8 (1.4) Hct (Hematocrit)0.42 (42) Hgb 136 (Hemoglobin)(13.6) Liver Function Panel:  AST 1.0 (60)  ALT 1.1 (64)  Alk Phos 2.5 (150)  GGT 70 (70)  LDH 3.2 (190)  T Bili 13.7 (0.8)  Spirometry: FEV1 2.5 L, Predicted 3.5 L  FVC 4 L, Predicted 4.2 L  Post Bronchodilator: FEV1 2.7 L  FVC 4.1 L  ABG: pH 7.36, pO2 8.6 (65), pCO2 6.0 (45), Bicarbonate 22, O2 sat 93%  Chest radiograph: consistent with COPD; mildly increased A/P diameter, flattening of diaphragms, diffuse scarring noted bilaterally; no evidence of acute infectious or malignant process  Drug/Non-Drug Plan for INSOMNIA related to depression: This patient has many other medical conditions that have much greater importance regarding his well being but ...Download file to see next pagesRead More
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