Patient Visit #4

Bree Miller, Emma Holmi, Mia Miles, and Kendyll

Erickson

PATIENT INFORMATION

RD

73 year old male

Proactive in his health

Disease States
Ulcerative Colitis
Migratory Arthritis
Cataract - left eye: Resolved via surgery 11/13
Medication List:
Atorvastatin (Lipitor)- 40mg qd for high cholesterol
Metoprolol succinate (Toprol XL)- 25mg qd for hypertension
Clopidogrel (Plavix)- 75mg qd to prevent clotting
Infliximab (Remicade)- infusion every 8 weeks for ulcerative colitis
Further Control of Disease States:
Diet: avoids certain food products known to aggravate RDs UC symptoms
Exercise: engages in physical exercise three times a week

SUBJECTIVE

No medication discontinuations

No ADRs at this time

He hopes to discontinue Remicade infusions

After upcoming infusion
Infusions are expensive
Insurance covers most
still notable co-pay
UC is well-controlled
Disease state regression
Associated symptom decrease

SUBJECTIVE: OTCS

OTC: Aspirin 325 mg for migratory arthritis

Arthritis in hands flaring up more often
Increased intake from 1 tablet, to 2 tablets every
morning
Does NOT create issues with child-proof caps
UPDATE: Flare-ups more under control

NOTE: Not patients actual X-ray

OBJECTIVE/ASSESSMENT

Adherence
Never misses any medication dose
Finds that his pill box is very helpful

PLAN

Primary Care Physician

Discuss arthritis pain with PCP at next appointment
UPDATE: Appointment yet to occur but symptoms have become
more manageable recently- still plans to discuss

Gastroenterologist
Discuss Remicade infusions and possibility of discontinuation in the
future
UPDATE: Plans to discontinue following next infusion

CATARACT SURGERY

Cataract removal in left eye- 11/13

Medications prescribed for surgery caused many ADRs

Anxiety
Nose Bleeds
Systolic BP increase from 120 to 190

Patient finished medications

Remained adherent despite issues

Health has returned to normal

Without ADRs; systolic blood pressure resolution (120mmHg)
Specific medications unknown (potentially NSAID, Antibiotic, and Glucocorticoid re
post-op guidelines)

DIMENSIONS OF WELLNESS
STRENGTHS

Social Wellness- meets with

friends at least twice a day

Physical Wellnessexercises three times a

week

Intellectual Wellness- stays

informed of current issues
and enjoys reading

Spiritual Wellness- prays

daily and has a strong faith

Career Wellness- being

retired gives him time for
hobbies

AREAS OF
IMPROVEMENT

Emotional Wellnessattempt to express

emotions with those
around him, including
his wife