Setting : large rural clinic; family practice clinic that employs physicians and nurse practitioners You open the chart to review for your next...

Setting: large rural clinic; family practice clinic that employs physicians and nurse practitioners

You open the chart to review for your next patient, and you see it is Larry M. Larry is a 60 year-old African American male with a history of hypertension. You note he is not due for a follow up at this time, so you look at the chief complaint.

CC: chest pain three days ago

You enter the room and introduce yourself. Larry M. is sitting in the chair. You ask what brings him in today. Larry M. smiles, shaking his head and says "My wife made me come, I feel fine." Three days ago Larry M. felt short of breath, had this heavy feeling in his chest, and he got kind of nauseous and sweaty. It lasted only about 3 minutes, and it has not happened again, but he does feel a little more tired. "It could be that I have not worked out since it happened."

PMHx: Reports general health as good. He Had been feeling great since starting to work out and lost weight. Had lots of energy and felt great until this episode three days ago. Now he is a little concerned because he feels a little more tired when he works out. He has not done as much strenuous running and has not worked out since the episode.

Childhood/previous illnesses: chicken pox.

Chronic illnesses: Hypertension- lifestyle changes recommended. Elevated cholesterol, lifestyle management was initiated.

Surgeries: T and A, cholecystectomy, vasectomy

Hospitalizations: None aside from surgeries listed above

Immunizations: Does not receive the flu shot.

Allergies: NKDA

Blood transfusions: None

Enjoys a beer or a glass of whiskey and the occasional cigar when playing poker with his buddies

Current medications: None

Social History: Married for 20 years, works as an architect.

Family History: Parents are deceased. Father had lung cancer and mother died from complications of a stroke. Brother died at 44 from malignant melanoma. Other sister and brother are healthy.

PE:

Height: 5'8" weight: 220 pounds; BMI 33.5 vital signs: BP 146/90 P 70 Sao2 97%

General: African American male in NAD. Alert, oriented, and cooperative. Pain: 0/10 at present

Skin: Skin warm, dry, and intact. Skin color is light skinned brown, no cyanosis or pallor.

HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp.

Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. No AV nicking noted.

Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender

Nose: Nares patent without exudate. Sinuses non-tender to palpation, Right-sided Deviation

Throat: Oropharynx moist, no lesions or exudate. Teeth in poor repair, gums reddened and receding, filled cavities noted. Tongue smooth, pink, no lesions, protrudes in midline.

Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Mild JVD in recumbent position

Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored. No rashes or vesicles noted on chest. CV: Heart S1 and S2 noted, RRR, no murmurs, noted. No parasternal lifts, heaves, and thrills. Peripheral pulses equally bilaterally. PMI 5th ICS displaced 4cm laterally. No edema in lower extremities.

Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted.

Labs from 3 months ago:

Total Cholesterol: 230

Ldl 180

Hdl 38

In office EKG: ST depression

Discussion Questions Part One:

What are the three most common, most likely differential diagnoses for this visit thus far with pathophysiology and evidence-based rationale?
What is your primary diagnosis causing Larry M.'s chest pain? Include ICD 10 codes (eliminate differentials)
List any relevant labs/diagnostic tests and link them to each diagnosis in the differential list. Remember to include evidence-based support for any testing you order along with rationale if you feel no testing is warranted.
What leads demonstrate the ST depression?
What other secondary diagnoses does Larry M. have that need to be addressed?
Include the rationale and a reference for your diagnoses
Based on JNC 8 guidelines, is Larry M. hypertensive?
Review the JNC 8 Recommendations for Antihypertensive Therapy and design a plan for Larry M. Please discuss the pharmacological properties of the therapy you chose including rationale for why this is the best choice for Larry M.
Plan for your primary diagnosis (Include conservative measures, referral, education and follow up) based on one current evidence-based journal article.
Further diagnostic work-up not included above.
Education