Answered step-by-step

Question
Answered step-by-step
Asked by coco0012

RT is a 45-year old Caucasian male who presents to your clinic because of pain in his right leg. He states that he woke up with the pain 3 days ago and that it has been continuous, although it hurts more when he walks. The pain is located behind his right knee and extends down into his calf. He rates the pain intensity as 3/10 at this time. The patient denies CP and SOB. He denies recent travel, immobility, and leg injury. The patient did start Atorvastatin 40 mg po daily daily for treatment of dyslipidemia approximately 3 months prior to this visit. He stopped the atorvastatin 5 days ago because he thought it might be causing his leg pain, but the pain has continued. He endorses compliance with his other medications. 

Physical exam: 

Physical exam of his right lower extremity shows a tight calf, warm to touch, and tender with 1+ pretibial pitting edema. Physical exam of his left lower extremity is unremarkable. Lower extremity pulses and sensation are normal bilaterally. Extremities show normal range of motion. The remainder of his physical examination is negative. 

Laboratory Results: 

Complete Metabolic Panel (CMP), Complete Blood Count (CBC), Uric Acid, TSH, T3/T4, lipid panel, and CK level are all within normal limits. 

Vitals: 

Patient is afebrile. Vitals in the office are as follows: BP 164/94, HR 60. Repeat vitals 20 minutes later in the office is BP 158/92, HR 62. Review of patient’s blood pressure log indicates his systolic blood pressure has been running high in the 150s and 160s over the past 2 months. 

Imaging:

Patient was instructed to have a vascular study completed at the outpatient vascular lab. Results of right lower extremity venous duplex ultrasonography: Acute DVT of right distal, popliteal, and peroneal veins. No compression or flow in these vessels. A CT of the chest was performed which came back negative for any abnormalities. 

Past Medical History: 

Hypertension, Hypothyroidism, and Hyperlipidemia Social History: RT denies use of alcohol or illicit drugs. He currently smokes about 1 pack of cigarettes per day. 

Current medications: Lisinopril (Zestril) 10 mg po once daily Levothyroxine (Synthroid) 75 mcg po once daily Atorvastatin 40 mg po once daily It is determined that RT is able to be safely treated as an outpatient for his current condition

1. List all of patient’s current medications (prior to clinic visit) and the indication for each medication. 

2. How would you diagnose and assess RT’s current clinical conditions? Provide supporting information. 

3. What changes to patient’s current medications or lifestyle would you make (if any)? 

4. What new medications would you recommend RT to begin taking? 

5. Provide counseling information to RT on all newly prescribed medications as well as his new diagnosis. 6. How would you monitor the safety and effectiveness for all newly implemented medications moving forward?

References (APA 7th edition) 

SCIENCE
HEALTH SCIENCE
NURSING
NURS 658

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