Mrs. Little is a 72 year old Hispanic female who presents to the clinic for an annual exam. She reports she has done well since her last visit. States she only checks her blood sugar twice a week, when she remembers. Has not been following her diabetic diet for the last few months. She denies any other issues.
Allergies: Strawberries, NKDA
Current medications: Metformin 1000mg bid, Amaryl 2 mg daily, Lisinopril 10mg daily
PMH: Diabetes, Hypertension
PSH: Hysterectomy, Rt Wrist surgery after MVA
Social: Tobacco: quit 2002, Denies alcohol or illegal drug use. Retired since 2015, worked as a bank teller.
Immunizations: Flu shot 9/2019
Family: Father: died at 92 of natural causes, Mother: died at 80 of stroke
HEENT: Denies any headache, nasal congestion, ear pain. Does report blurry vision at times
Cardiovascular: Denies chest pain
Respiratory: Denies any SOB, DOE, orthnopenia
GI: Denies any abdominal pain.
GU: Denies any painful urination, urgency, hesitancy
Musculoskeletal: Reports some knee pain with bending, walking long distances. Denies any swelling or redness
Psychiatric: Denies suidicial ideations, depression. Does report difficulty falling asleep
Endocrine: Reports she has gained 15 pounds over the last year.
Hematologic/ Lymphatic: Denies any bruising
Vital signs: Ht: 62, Wt: 198, BP 166/82, HR 84, Resp: 16, SaO2: 96%
Constitutional: Well developed, overweight female
HEENT: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth with dental cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses
Cardiovascular: RRR, No murmurs or rubs noted. No peripheral edema noted
Respiratory: Clear bilaterally all fields.
GI: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organo-megaly noted.
Musceloskeletal: Heberden and Bouchard nodes noted to bil hands.
Integrementary: Skin warm and dry, No rashes noted
Neuro: Follows commands without difficulty
Working with your group, utilize the above case study a, develop a Voice Over PowerPoint presentation for your patient covering the covering problems identified and the content in Unit 3 of Edelman, Kudzama, & Mandle (2018). Include the following:
· Screening [Immunizations are to be addressed explicitly-ie. up to date- and define, or not up to date- management]
· Health Education
· Nutrition Counseling for Health Promotion
· Stress Management
· Complementary and Alternative Strategies.
· Incorporate the application of a mobile app either by practitioner or population (ie, use of CDC Immunization App to reference Catch Up Schedule, or Fitbit© App and mobile technology for fitness tracking).