FNP Case Study
Pharmacology Case Study #1
Name
Mississippi University for Women
Nu 501 – Advanced Pharmacology
1/22/2010
CC: Pain in left side of face, jaw, and head x 1 wk
HPI: 60 y/o BM with hx of HTN presents with pain on left side of face, jaw, and head x 1wk. Pt denies any trauma. Reports left facial pain x 1 wk, throbbing, starts in jaw area and extends to head, “8” on pain scale 0 -10, pain worsens when eating and drinking, especially cold drinks.
PMH: Diagnosed with HTN at age 40 managed well with medication, diet, and exercise. Denies any history of stroke, heart disease, lung disease, diabetes, or cancer.
PSH: Tonsillectomy @ age 5
FH: Mat: mother – HTN, heart disease Pat: grandmother – HTN
SH: Married for 40 yrs. Retired from welding in 2008 after working for 36 yrs. Wife is a retired school teacher. One daughter age 40, one son age 36, four grandchildren ages 4, 8, 15, and 18. Attends grandchildren’s school events and ball games. Attends local church twice a wk. Plays cards every Thursday night with the guys. Pt denies the use of alcohol, tobacco, and recreational drugs.
Allergies: PCN, Cipro, ASA: PCN – “my throat swells up and I get short of breath”, Cipro – “rash all over”, ASA – “makes my stomach hurt”
Current Meds: Lisinopril 10mg 1 pill by mouth every morning for high BP.
ROS: General Health: Good health with controlled HTN. Diet: Low Salt Exercise: Walks 30 minutes a day with wife around neighborhood and does yard work every wk such as mowing grass and managing small vegetable garden. Integumentary: Denies any skin lesions, rashes, moles, or bumps. HEENT: Denies any problems with seasonal allergies. Reports 1-2 sinus infections every yr. Reports 3 ear infections in past. Denies any sinus drainage, pain, pressure, cough, sore throat, or ear pain today or within the last 2 -3 wks. Denies any visual changes or dizziness. Reports mild tooth sensitivity and toothache on left lower side that
Name
Mississippi University for Women
Nu 501 – Advanced Pharmacology
1/22/2010
CC: Pain in left side of face, jaw, and head x 1 wk
HPI: 60 y/o BM with hx of HTN presents with pain on left side of face, jaw, and head x 1wk. Pt denies any trauma. Reports left facial pain x 1 wk, throbbing, starts in jaw area and extends to head, “8” on pain scale 0 -10, pain worsens when eating and drinking, especially cold drinks.
PMH: Diagnosed with HTN at age 40 managed well with medication, diet, and exercise. Denies any history of stroke, heart disease, lung disease, diabetes, or cancer.
PSH: Tonsillectomy @ age 5
FH: Mat: mother – HTN, heart disease Pat: grandmother – HTN
SH: Married for 40 yrs. Retired from welding in 2008 after working for 36 yrs. Wife is a retired school teacher. One daughter age 40, one son age 36, four grandchildren ages 4, 8, 15, and 18. Attends grandchildren’s school events and ball games. Attends local church twice a wk. Plays cards every Thursday night with the guys. Pt denies the use of alcohol, tobacco, and recreational drugs.
Allergies: PCN, Cipro, ASA: PCN – “my throat swells up and I get short of breath”, Cipro – “rash all over”, ASA – “makes my stomach hurt”
Current Meds: Lisinopril 10mg 1 pill by mouth every morning for high BP.
ROS: General Health: Good health with controlled HTN. Diet: Low Salt Exercise: Walks 30 minutes a day with wife around neighborhood and does yard work every wk such as mowing grass and managing small vegetable garden. Integumentary: Denies any skin lesions, rashes, moles, or bumps. HEENT: Denies any problems with seasonal allergies. Reports 1-2 sinus infections every yr. Reports 3 ear infections in past. Denies any sinus drainage, pain, pressure, cough, sore throat, or ear pain today or within the last 2 -3 wks. Denies any visual changes or dizziness. Reports mild tooth sensitivity and toothache on left lower side that
References: Edmunds, M. W. & Mayhew, M. S. (2009). Pharmacology for the primary care provider. St. Louis, Mo. Mosby, Inc. Merck Manual (2006). The merck manual of diagnosis and therapy. Whitehouse Station, NJ. Merck & Co., Inc. Mettler, F. A. (2005). Essentials of radiology. Philadelphia, PA. Elsevier, Inc. Uphold, C. R. & Graham, M. V. (2003). Clinical guidelines in family practice. Gainesville, Fl. Barmarre Books, Inc.