CASE STUDY
Case V: Bladder issue (Nervous System)
A 50-year-old male patient presents to your clinic with a complaint of swollen ankles for the past 2 weeks. He has a history of hypertension, which has been well controlled for 1 year with a combination of clonidine and a diuretic. His blood pressure today is 160/92 mm Hg, which is significantly higher than measured during his last three visits to your office. While reviewing his medication list, he tells you that he no longer takes the diuretic because he is up to go to the bathroom at night and it is causing him to lose sleep.
Discussion Questions:
1. Describe the most likely cause of his ankle edema.
2. What type of autonomic pharmacology drug used to prevent urinary retention? Provide the mechanism of action.
3. How would you modify the treatment plan?
4. What patient education is needed by this male patient?
I. Introduction –Case Presentation to answer questions related to your case 20 Ppoint
II. Body
A. 1. Subjective CC (5 points)
2. History of present illness (5 points)
3. Past Medical History — as appropriate to Case (5 points)
4. Family History — as appropriate to Case (5 points)
5. ROS — as appropriate to Case (5points)
B. Objective
1. Systems assessed with significant results(5 points)
2. Diagnostic tests performed and results(5 points)
C. Assessment
Differential Diagnosis with ICD-9 codes
Rationales (pertinent positives and negatives)(5points)
D. Plan
1. Medication: Describe the actions, application, and side effects of drugs used in the treatment of this condition
2. Alternatives
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