history of a headache and chest pressure.

/in /by

C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.

PMH

Allergic Rhinitis

Depression

Hypothyroidism

Family History

Father died at age 49 from AMI: had HTN

Mother has DM and HTN

Brother died at age 20 from complications of CF

Two younger sisters are A&W

Social History

The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.

Medications

Zyrtec 10 mg daily

Allergies

Penicillin

ROS

States that his overall health has been fair to good during the past year.

Weight has increased by approximately 30 pounds in the last 12 months.

States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.

Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.

Denies any nausea, vomiting, diarrhea, or blood in stool.

Self treats for occasional right knee pain with OTC Ibuprofen.

Denies any genitourinary symptoms.

Vital Signs

B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.

HEENT

TMs intact and clear throughout

No nasal drainage

No exudates or erythema in oropharynx

PERRLA

Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema

Neck

Supple without masses or bruits

Thyroid normal

No lymphadenopathy

Lungs

Mild basilar crackles bilaterally

No wheezes

Heart

RRR

No murmurs or rubs

Abdomen

Soft and non-distended

No masses, bruits, or organomegaly

Normal bowel sounds

Ext

Moves all extremities well

Neuro

No sensory or motor abnormalities

CN’s II-XII intact

DTR’s = 2+

Muscle tone=5/5 throughout

What you should do:

  • Develop an evidence-based management plan.
  • Include any pertinent diagnostics. (Screening Chest Xray/EKG, LABS, referrals to cardiologist to eval cardiovascular disease, smoking cessation education, nutritional consult) 
  • Describe the patient education plan. (lifestyle changes, weight management, AHA/DASH diet)
  • Include cultural and lifespan considerations. ( Common in African American )
  • Provide information on health promotion or health care maintenance needs.
  • Describe the follow-up and referral for this patient.
  • Prepare a 3 page paper (not including the title page or reference page).