Week 3: Case Discussion: Cardiovascular Part One

Week 3: Case Discussion: Cardiovascular Part One

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Week
3: PBL Case Discussion: Cardiovascular

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 5^th 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

·
EKG In office TODAY:
ST depression

Click here to access the EKG (Links to an external site.)Links to an external site.

Discussion Questions:

·
What is your primary
diagnosis causing Larry M.’s chest pain? Include ICD 10 codes (no
differentials)

·
List any relevant
labs/diagnostic tests and link them to Larry’s specific case.
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 ACA 2017
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 referral, education and follow up) based on one
current evidence-based journal article.

·
Further diagnostic
work-up not included above

·
Medications

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