Assignment
Case Study
New Patient to the Clinic
A 58 year-old Hispanic male, with limited English proficiency although he can read English, presents to your primary care practice for an initial visit. Using translator via computer, patient states that he is new to the area and is looking for a primary care provider.
Present Illness: Translator states that the patient has diabetes and high blood pressure. He recently moved to this area and was last seen by his previous provider approximately 2 months ago. At that time, the provider changed his medications, and he did not keep his follow up appointment for his blood pressure. Patient does not monitor blood pressure at home. Translator states the patient is not sure why the provider changed his medications. Translator states patient has been complaint with current medication regimen.
Medical History
Childhood Illnesses: chicken pox-age 7, mumps age 10, denies croup, pertussis, rheumatic fever, scarlet fever, or polio. Pt did not receive regular immunizations as a child.
Adult Illnesses: Hypertension-diagnosed 4 years ago, diabetes mellitus-diagnosed 2 years ago, obesity-most of his adult life
Psychiatric Illnesses: describes symptoms of depression off and on since childhood, but has never been medically treated
Accidents and Injuries: denies any history Allergies: no known drug or food allergies
Immunizations: last tetanus shot was at age 24; patient has never had influenza immunization or pneumococcal immunization
Screening test: last dental exam 2 years ago; last eye exam 5 years ago; last provider did blood work and patient brought a copy with him today
Environmental hazards/use of safety measures: Patient always uses seatbelt in automobiles. He has smoke detectors in his home. Hot water heater set at 128° F.
Current Medications: (Patient brought in his pill bottles.) amlodipine 10 mg by mouth daily hydrochlorothiazide 12.5 mg by mouth daily metformin 500 mg by mouth 2 times a day
Social History
Patient has been married for 29 years and states his marriage is "ok." He denies any physical, mental, or financial abuse. He did not complete high school because he had to go to work to help support his family. Patient admits that he smokes 1⁄2 pack per day for approximately 20 years and he denies any regular exercise routine. He states that he consumes alcohol in "moderation." (Specific questions reveal approximately 4-7 alcoholic drinks per week-usually a beer with dinner, but may have a cocktail on rare occasions.) Patient drinks 4-6 cups of coffee daily in addition to 3-4 caffeinated beverages (such as Coke or Pepsi). He denies the use of illicit drugs.
Surgical History
None
Family History
Paternal Father is alive-in poor health-COPD, diabetes, history of surgery for colon cancer 3 years ago, history of prostate cancer 5 years ago
Paternal grandfather and grandmother both deceased-killed in automobile accident when patient was a small child
Maternal Mother is deceased from breast cancer when patient was age 12
Maternal grandmother is age 92, lives in a nursing home, has Alzheimer disease, hypertension, and kidney disease.
Maternal grandfather is deceased from a work accident and had a history of diabetes.
Review of Systems
General health-reports usual health as "good" Patient states that he has gained approximately 20 pounds in the last several years. Denies fatigue, weakness, fever, or sweats.
Skin-no history of skin disease. Denies change in skin color, pigmentation, pruritus, rash, or lesions
Hair-no hair loss or change in texture.
Head-denies headaches, head injury, dizziness, syncope, or vertigo
Eyes-uses reading glasses that he bought at the drug store. Denies eye pain, double vision, inflammation or discharge.
Ears, Nose, Throat-denies any hearing loss, discharge, tinnitus, or exposure to environmental noise. Denies any other problems.
Neck-denies pain, limitation of motion, lumps or swollen glands.
Respiratory-no history of lung disease, denies any shortness of breath, wheezing, or orthopnea Cardiac-denies any problems
Gastrointestinal-denies history of ulcers, liver, or gallbladder disease, jaundice, appendicitis, or colitis. Appetite good with no recent changes. Denies food intolerance, heartburn, pain in abdomen, nausea, or vomiting. Daily bowel movements soft brown, no rectal bleeding, pain or hemorrhoids
Urinary-no history of stones or urinary tract infections. Denies dysuria, but admits to some frequency, urgency, hesitancy and straining-particularly at night
Genitalia-normal male genitalia. Denies self-testicular exam. Denies history of sexually transmitted diseases. Complains of erectile dysfunction
Musculoskeletal-mild aching bilaterally in knees usually after walking or standing for long periods, with some limitation in range of motion. Denies any past trauma, swelling, redness, deformity, stiffness, muscle pain, weakness or past history of arthritis
Neurological-denies history of seizure disorder, stroke, syncope, numbness, tingling, weakness, tremor, and problems with coordination. Reports good memory
Hematologic-denies excessive bruising. Denies exposure to toxins and never had a blood transfusion
Endocrine-denies problems with hot or cold environments. Denies any change in skin, hair, appetite, or nervousness
Physical Exam
General Survey-Well-developed, moderately obese, middle-aged Hispanic male who walked and moved easily and responded to questions via translator. He was neatly dressed.
Height without shoes 5'11" Weight (undressed with gown on) 221 lbs Blood pressure taken with wide cuff at rest for 5 minutes
RA, sitting 146/88, HR 76 RA, lying 140/90, HR 72 LA, lying 142/96, HR 72
Respirations 16, unlabored
Skin-Uniformly brown in color, warm, dry, intact, good turgor. Several 0.4-0.6 raised, rough lesions on his arms and legs that have a "stuck-on" appearance. On the back of his neck just under his hairline is a "waxy" appearing lesion that he says has been there for a while-he says that "thing just won't go away." He also admits that it bleeds easily if he scratches if accidently. No birthmarks or edema. His hair is cut short with thinning at the top and normal texture. Nails without clubbing or discoloration.
Head-Normocephalic, without lesions, lumps, or tenderness. Face, symmetric
Eyes-Acuity by Snellen chart-OD 20/20, OS 20/20, OU 20/20, Unable to read near vision chart. Visual fields full by confrontation. EOMs intact without nystagmus. No ptosis, lid lag, or discharge. Corneal, light reflex symmetric. Sclera white, without lesions or redness. PERRLA. Fundi-discs flat with sharp margins, without arterial narrowing, A-V nicking, or retinal hemorrhage.
Nose-No deformities or tenderness to palpation. Nares patent. Mucosa pink without lesions. Septum midline, without perforation or sinus tenderness.
Mouth-Mucosa and gingival pink, without lesions or bleeding. Teeth in good repair. Tongue symmetric, protruded midline without tremor. Pharynx pink, without exudates. Uvula rises midline on phonation. Tonsils absent. Gag reflex present.
Neck-supple with full ROM. Symmetric, without masses, tenderness, lymphadenopathy. Trachea midline. Thyroid nonpalpable, nontender. No JVD. Carotid arteries 2+ bilaterally, without bruits.
Lymph Nodes-Negative cervical, axillary, epitrochlear, or inguinal nodes.
Thorax and lungs-Nonlabored effort. Chest expansion symmetric. Breath sounds vesicular with no adventitious sounds.
Cardiovascular-S1S2 present without S3 or S4 or murmurs. Apical impulse at 5th ICS left MCL, precordium, without abnormal pulsations.
Abdomen-Abdomen soft, without masses, tenderness. Bowel sounds present. Liver span 7 cm in right MCL. Abdominal aorta palpable without lateralization, measuring approximately 2 cm. No abdominal bruits. No inguinal lymphadenopathy or CVA tenderness.
Genital/rectal-deferred per patient request
Peripheral vascular-without redness, cyanosis, lesions, edema, varicosities, and calf tenderness. All peripheral pulses present 2+ and equal bilaterally. Feet are symmetrically warm with normal pigmentation and hair distribution. Lower extremities and feet without stasis, rubor, ulcer, or thickened and ridged nails
Musculoskeletal-Temporomandibular joint without slipping or crepitation. Spine without tenderness, full ROM, without kyphosis, lordosis, or scoliosis. Extremities symmetric with full ROM, without pain or crepitation.
Neurologic-Alert and cooperative, thoughts coherent considering language barrier, oriented x3. CNII-XII intact.
Sensory: pinprick light touch, vibration, intact. Foot exam with monofilament without decreased sensation
Motor: Normal strength, bulk and tone
Cerebellar: Finger-to-nose intact. Romberg negative without pronator drift Gait: Normal stance and cadence. DTRs 2+ all extremities, toes down-going
Mental Status-Appearance, behavior, and speech appropriate. Remote and recent memories intact. Affect appropriate without evidence of hallucinations, delusions, without suicidal or homicidal ideation PHQ-9 score 14
Laboratory studies
EKG-normal sinus rhythm
HgbA1C - 7.6%
Lipid panel-Total cholesterol 181, triglycerides 78, HDL cholesterol 53, LDL cholesterol 112 CBC-RBC: 3.6 mil/mm3
WBC: 7.2 K/mm3 PLT: 164 K/mm3 HGB: 12.2 g/dL HCT: 33.8%
PSA-5.6
Task
For the above patient, give full detailed information:
I. List diagnoses based on the subjective, objective, and lab data.
II. Discuss management plans including any additional examinations, tests, and pharmacologic and non-pharmacologic management for each diagnosis. Be sure to include proposed time frame of each plan (example: when do you recheck each, what do you expect to see when you recheck, what will you do if you see expected results, and what will you do if you do not see expected results).
III. For each pharmacologic agent, discuss contraindication, side effects, pharmacokinetics and pharmacodynamics of the proposed agent. Include dosing schedule with rationale. Give rationale why you choose this product and why you did not choose other classes of medication, or other agents within that classification.
IV. Will you make any referrals for this patient? Why, or why not? If so, for which diagnoses?
V. List all routine screenings that you would recommend for this patient.