[Expert Solution]: Mr

Mr. Carol O’Conner is an 82-year-old that comes to the office today due to some increase in bruising and some bleeding gums when he brushes his teeth. He has recently stopped drinking and he attends AA sessions weekly. His family, wife and 3 children, held an intervention for him 2 months ago and he started his sobriety journey after that. He currently lives with his wife in their home of 51 years and has a close relationship with the rest of his family. He is a retired farmer, one of his sons now runs most of the day-to-day work, Carol does still help with bookkeeping. His medical history is significant for his history of alcohol misuse, he had shingles on the left side of his chest 6 weeks ago – now resolved, he also has glaucoma and hypothyroidism both of which he follows up with and has been good about keeping appointments. He never smoked, no recent falls or other injuries. VS: BP 140/78 Pulse 80 Resp 18 Temp 98.2 02 Sat 98% on RA PMH: as stated in case Allergies: PCN – rash Medications: • Levothyroxine 75mcg 1 po daily • Timolol ophthalmic 0.5% drop both eyes BID • Ibuprofen 200mg 1 or 2 po PRN aches and pains • Multivitamin, One a Day Men’s, 1 po daily Diagnostics/Assessments: Last TSH 3 months ago 1.7, last seem by ophthalmology 4 months ago, f/u appointment with ophthalmology in 8 weeks. Today’s visit CBC: TEST RESULT REFERENCE RANGE WBC 5.2 4.0 – 11.0 K/mm2 Hemoglobin 13 11 – 16 g/dL Hematocrit 42 % 35% – 48% Platelets 100 L 150 – 450 x 109/L Neutrophils % 59.9 % 37 – 80 (%) Lymphocytes % 38.3 % 23.0 – 45.0 (%) Monocytes % 7.6 % 2.5 – 14 (%) Eosinophils % 1.5 % 0.5 – 4.0 (%) Basophils % 0.8 % 0.0 – 2.0 (%) ANSWER THE FOLLOWING QUESTIONS (incorporate them into your SOAP note ROS and PE): Mr. Carol O’Conner is an 82-year-old What would your ROS questions/ results look like? this is a virtual note – you can add what you think would be appropriate. 1. What physical examinations would you do for this patient? 2. What positive findings would help you with the diagnosis? 3. What other diagnostic testing would you do for this case? 4. What is your primary diagnosis? List 3 differentials as well. 5. What can be some contributing factors to this individual’s diagnosis? 6. Explain some of the treatment options for this person’s diagnosis. 7. Describe your follow-up plan and referrals for this person.