Problem
Cardiovascular Case Study
A 49-year-old African American male who is a house painter whom you haven't seen in several years presents with chronic fatigue and mild chest pain frequently relieved by taking a break from painting. He's married to a 47-year-old woman with MS and has two married children and one grandchild living nearby. He also complains of frequent eructation, flatulence, and indigestion after eating. He was told when he was 30 pounds lighter that he could control his hyperlipidemia by diet. His past medical history includes anxiety, cholecystectomy, and vasectomy. CC: "I'm always tired, and I have this annoying chest pain when I climb a ladder."
Physical exam:
Vital signs: Blood pressure is 166/88. Height is 6'0". Weight is 242 pounds.
Lab results: TC is 230. LDL is 180. HDL is 32.
Identify any cultural, socioeconomic, religious or psychosocial issues (list 3) that you have considered in your treatment plan.
Case specific question(s).
1) What specific classes of antihypertensives might be most appropriate for this patient and why?
2) When would you ask the patient to return to the office for a follow-up visit?
3) Identify preventative care that would be appropriate for this patient (immunizations, screenings, etc.). (2 points: 1 point for appropriate preventative care, 1 point for RATIONALE of preventative care)
4) Which Centers for Medicare & Medicaid Services Evaluation & Management (CMSE&M) code would you assign this visit? Provide rationale for your answer.