Reference no: EM133243576
Question: 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.
Students are to respond to all of the following questions:
What additional subjective data (list 5) would you collect? (10 points: 2 points for each appropriate subjective data)
What additional objective data (excluding laboratory or diagnostic studies, list 5) would you collect? (5 points: 1 point for each appropriate objective data)
List and prioritize differential diagnoses (list 4) you would consider. For each differential diagnosis proposed, list specific information from the case study or from data you have suggested that supports the diagnosis. (20 points: 3 points for each appropriate diagnosis, 2 points for each RATIONALE of diagnosis)
What laboratory or diagnostic studies should be considered to assist with or confirm the diagnosis and what would be the EXPECTED FINDINGS of these studies? (10 points: 5 points for appropriate studies, 5 points for expected findings of studies)
Outline your treatment plan:
• Recommended prescription therapy: (10 points)- 5 points for appropriate prescriptive therapy (including dosing)- 5 points for RATIONALE of therapy
• Recommended non-prescription (OTC, complementary) therapy (list 2):
Propose referrals to other health care professionals and indicate the purpose (goal) of the referral.
Describe patient/family teaching topics (list 3) that would be appropriate for this case.
Identify any cultural, socioeconomic, religious or psychosocial issues (list 3) that you have considered in your treatment plan.
Case specific question(s).
- What specific classes of antihypertensives might be most appropriate for this patient and why?
- When would you ask the patient to return to the office for a follow-up visit? Identify preventative care that would be appropriate for this patient (immunizations, screenings, etc.).
Which Centers for Medicare & Medicaid Services Evaluation & Management (CMS E&M) code would you assign this visit? Provide rationale for your answer. (1 point: 0.5 point for appropriate code, 0.5 point for RATIONALE of code)