Chief Complaint “I feel like I’m constantly tired and fatigued and…

Question Answered step-by-step Chief Complaint “I feel like I’m constantly tired and fatigued and… Chief Complaint”I feel like I’m constantly tired and fatigued and my tongue is sore and swollen, making it extremely difficult for me to eat or drink anything.” HPIA  65-year-old man who presents to your outpatient clinic with his wife. He claims that his fatigue and lethargy have been going on for years but have been worsening over the last 4-5 months to the point that he always feels tired. Additionally, he claims that over the last 2-3 weeks his tongue has become extremely painful and swollen and that he struggles to eat. His appetite has diminished because he tries to avoid eating anything that could worsen his pain, and he feels “fuller” more quickly than usual. On questioning, he also mentions a slight tingling and numbness in his feet that seems to worsen when finishing any physical activity. The patient has lost about 10 lb over the last 3 months, and he states that he feels like he is running a constant low-grade fever. His wife adds that she feels that he is becoming more confused, and this has been worsening over the last several years. PMHxCOPDType 2 diabetes mellitusGout MedicationsDocusate sodium 100 mg PO Q 12 HAlbuterol MDI two puffs Q 6 H PRNFluticasone/salmeterol 250/50 one puff Q 12 HTiotropium 18 mcg one puff dailyMetformin 1000 mg PO Q 12 HGlyburide 5 mg PO dailyColchicine 0.6 mg PO dailyAllopurinol 300 mg PO dailyAllergiesPenicillin (hives), Levofloxacin (anaphylaxis), NKFA, denied latex allergy FamilyHxFather alive (85 years old) with CAD, HTN, glaucoma, and type 2 DMMother deceased at age 75; had HTN, Alzheimer dementia, and CKD   SocHxMarried for 42 years, lives with his wife; has two children (one son and one daughter) who are both healthy and live in the area; (+) tobacco, 1.5 ppd since age 24; (-) alcohol, (-) illicit drugs; is a retired pharmacist with good health insurance ROSComplains of tongue pain and tingling sensation in his toes; (-) SOB, headache, chest pain, psychiatric abnormalities, polyuria, or polydipsia; denies any visual changes, constipation, diarrhea, or urinary retention, lightheadedness when standing Physical ExaminationConstitutionalElderly Caucasian male; moderately overweight in no acute distress with normal affect and speech; seems slightly irritated and exceptionally fatigued VSBP 123/87 mmHg, P 106 bpm, RR 16, T 38.0°C; O2 sat 94% on room air; Wt 92 kg, Ht 6?0?, BMI 27.4 SkinPale, turgor normal, no rashes or lesions HEENTNC/AT, PERRLA, EOMI, conjunctivae pink, sclera white, (-) photophobia, nares patent, no sinus tenderness, TMs visualized bilaterally, (+) red, smooth, swollen, tender tongue with loss of papillae, neck supple without masses, trachea midline, no lymphadenopathy, no thyromegaly, no JVD, no bruits  LungsSymmetrical rise/fall of thorax, non-tender, diminished tactile fremitus to bases, no bronchophony noted, resonance noted to all fields with percussion, minor scattered wheezing and rhonchi present to all fields CardiacS1, S2, tachycardic, RR, no m/r/g, peripheral pulses +2 AbdFlat abdomen, non-distended, BS x4 quadrants, no bruits appreciated, non-tender, mild splenomegaly, no hepatomegaly, no masses, general tympany noted Genit/RectDeferredExtNo erythema, pain, or edema; no joint redness or swelling; no limb weakness NeuroA & O × 3; CN II-XII intact; EOMI; motor: coordination intact, Romberg negative, gait steady; sensory:  decreased pinprick in both lower extremities; decreased vibratory sensation in both lower extremities; decreased temperature sensation in both lower extremities; DTRs +2 Labs (All Fasting)Na 136 mEq/LHgb 8.4 g/dLAST 30 IU/LIron 124 mcg/dLK 3.5 mEq/LHct 25.3%ALT 24 IU/LFerritin 100 ng/mLCl 108 mEq/LRBC 2.09 × 106/mm3Alk phos 79 IU/LTransferrin 229 mg/dLCO2 28 mEq/LPlt 91 × 103/mm3T. bili 0.8 mg/dLAntiparietal cell antibodies (-)BUN 13 mg/dLWBC 3.5 × 103/mm3D. bili 0.4 mg/dLLDH 140 IU/LSCr 1.0 mg/dLMCV 121 ?m3T. chol 153 mg/dLB12 101 pg/mLGlu 134 mg/dLMCH 40 pgUric acid 4 mg/dLFolate 12.3 ng/mLA1C 6.8%MCHC 33.2 g/dL  TSH 3.4 mIU/LReticulocyte (corr) 0.7%   Peripheral Blood Smear MorphologyMacro-ovalocytosis, hypersegmented granulocytes, large platelets, macrocytic red blood cells with megaloblastic changesBlood smear with enlarged hypersegmented neutrophils, one with eight nuclear lobes (large arrow) and macrocytes (small arrows)  Case Study Questions What are the monitoring parameters for any drug listed in question 2. Be sure to address appropriate follow-up times and any necessary testing or labs. 2.    What patient education should be provided in order achieve a therapeutic effect and minimize any potential harm?  Be      sure to address any lifestyle modifications/non-pharm therapy, drug-drug interactions, drug-diet interactions, and        adverse drug effects.   Biology Science Physiology NUR 546 Share QuestionEmailCopy link Comments (0)

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