Mr. Collins Patient (Case study)

Mr. Collins is a 52 year old Caucasian male who reports today for an annual exam for insurance purposes. He has not seen a provider in over 10 years. He states he is in good health but has noticed his feet swelling more lately. He also reports his heart “skipping” beats but has not seen anyone about this. He denies taking any medications.
Allergies: Penicillin
Current medications: BC powder
PMH: GERD
PSH: Tonsillectomy
Social: Tobacco: 2 PPD smoker, Alcohol 5-6 beers daily, Denies illegal drug use. Drinks 4 cups of coffee, multiple sodas a day, 2-3 bottles of water, eats fast food during the week, Does not exercise, Works as a plumber
Immunizations: Does not remember
Family: Father: died at 67 from MI, Mother: alive, + HTN, Hyperlipidemia, CKD stage II
ROS:
Constitutional: Well developed, thin male in no acute distress
HEENT: Denies any headache, nasal congestion, ear pain.
Cardiovascular: Denies chest pain
Respiratory: Denies any SOB, reports cough, with whitish sputum. Reports some wheezing at times when walking
GI: Denies any abdominal pain, does report some heartburn
GU: Denies any painful urination, urgency, hesitancy
Musculoskeletal: Denies
Neurological: Denies
Psychiatric: Denies suicidal ideations, depression.
Endocrine: Denies.
Hematologic/ Lymphatic: Denies any bruising, easy bleeding
OBJECTIVE:
Vital signs: Ht: 70, Wt: 165, BP 160/80, HR 84, Resp: 18, SaO2: 96%
Constitutional: Well developed, thin white male
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: Faint expiratory wheezes noted bilaterally, clears with coughing.
GI: Abdomen round, soft, with bowel sounds noted in all four quadrants. Nontender with palpitation

GU: Deferred
Integumentary: Skin warm and dry, No rashes noted
Neuro: Follows commands without difficulty.
INSTRUCTIONS

  • Utilizing the above case study, (covering the problems identifiied in the case and content in Unit 3 of Edelman, Kudzama, & Mandle (2018).)
  • Answering the following question according to Patient Mr. Collins:
    1- Stress Management
    2- Complementary and Alternative Strategies.

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