Evidence-Based Project

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

Working with your group, utilizing the above case study, develop a Voice Over PowerPoint presentation for your patient covering the problems identifiied in the case and 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

· Exercise

· Stress Management

· Complementary and Alternative Strategies.

· Incorporate the use 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).