Need health and medical help with an Endocrine case study

Description

Endocrine case study

CC/PMI:  GB is a 65 year-old male who comes in for a check-up on the request
of his spouse.  His last check-up was 10 years ago.  He has no complaints other
than some leg numbness and tingling from time-to-time and feeling thirsty and
tired most of the time.

SH:  no smoking or alcohol consumption

Physical Examination:GEN:  well-nourished, slightly obese
male
VS:  BP 170/100, Hr 70, RR 12, T 98.7, Wt 89kg, Ht 5’8″
HEENT: 
PERRLA
COR:  RRR, NMRG
CHEST:  CTA
NEURO:  monofilament test shows
decreased peripheral sensation
EXT: normal

Laboratory (fasting):






















Na 140

Cl 100

BUN 32

BG 250

K 3.7

HCO3 24

SCr 1.9

ALT 35

AST 40

Alb 4.0

Ca 9.0

TP 7

Cholesterol 250

 

UA: SG 1.012, pH 6.4, +++ protein

 

Questions

  1. What major problems can you identify with this patient?
  2. What is your assessment and plan for each problem?
  3. Provide pharmacological and nonpharmacological care (don’t forget to be
    specific).  Will you add any new medications?
  4. How will you monitor each problem and each medication included in your plan?
  5. When will you suggest following up with the patient?
  6. Is there any laboratory monitoring that will need to be conducted to assure
    the safety of the patient?

 

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