Setting: large urban city; family practice clinic that employs physicians and nurse practitioners
It's another busy day at the clinic. You open the chart to review for your next patient, and you see it is Jeremy M. Jeremy is a 52 year-old white male with a history of hypertension. He was taken off HTN meds at last visit almost three months ago. 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. Jeremy is sitting in the chair texting on his cell phone. You ask what brings him in today. Jeremy smiles, shaking his head and says "My wife made me come, I feel fine." Three days ago Jeremy 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, and I have more energy when I walk on the treadmill."
PMHx: Reports general health as good. 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 shortened his workout since the episode.
Childhood/previous illnesses: chicken pox.
Chronic illnesses: Hypertension, medication stopped three months ago. He cannot recall the medication. 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: 5'10" weight: 240 pounds; vital signs: BP 146/90 P 70 Sao2 97%
General: Caucasian male in NAD. Alert, oriented, and cooperative. Pain: 0/10 at present
Skin: Skin warm, dry, and intact. Skin color is pale pink, no cyanosis or pallor.
HEENT: Head normocephalic. 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 nontender
Nose: Nares patent without exudate. Sinuses nontender to palpation.
Throat: Oropharynx moist, no lesions or exudate. Teeth in good repair, no 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
EKG- attached, ST segment depression
Discussion Questions Part Two:
What leads demonstrate the ST depression?
What is your primary diagnosis causing Jeremy's chest pain? Include ICD 10 codes (eliminate differentials)
What other secondary diagnosis does Jeremy have that need to be addressed?
Include the rationale and a reference for your diagnoses.
Review the JNC 8 Recommendations for Antihypertensive Therapy and design a plan for Jeremy. Please discuss the pharmacological properties of the therapy you chose including rationale for why this is the best choice for Jeremy.
Plan for each primary diagnoses based on one current evidence-based journal article.
Further diagnostic work-up not included above
Medications