One to three pages of scholarly writing in paragraph format, not counting the title page or reference page Brief introduction of the case

One to three pages of scholarly writing in paragraph format, not counting the title page or reference page

Brief introduction of the case

Identification of the main diagnosis with supporting rationale

Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out

Diagnostic plan with supporting rationale or references

A specific treatment plan supported by recent clinical guidelines

Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric.

Patient Name: Jose Martin 54 yo male

 

Past Medical History

 

Mr. Martin reports no history of hypertension, hypercholesterolemia, or diabetes. He reports no history of kidney disease, eye problems, peripheral vascular disease, heart disease, or strokes. No history of gout or arthritis. His last vaccinations were over 10 years ago, and he has not had any preventive services for his age. He reports no other medical problems.

 

Medications

 

None. Does not use complementary or herbal remedies.

 

Past Surgical History

 

None.

 

Social History

 

Mr. Martin speaks English and Spanish. He is married to his wife and has one daughter, age 16. He and his family moved here from the Dominican Republic 10 years ago. He works as a taxi driver for 12-hour shifts, six days a week. His wife works as a seamstress. They are both uninsured. His daughter gets her medical care in her high school clinic. He and his family live in a two-bedroom apartment near the clinic. He is sexually active with his wife only. He does not drink alcohol or use recreational drugs. He does not smoke. The patient has good emotional support from his family and friends. He admits to occasional financial stressors, but his family is never short of food or clothing. However, his daughter may be going to college soon and his rent continues to increase annually, which worries him.

 

Diet History

 

Mr. Martin states that he eats a lot of fast food during his long and busy taxi shifts. He eats better when he is at home. His wife makes “chicken without the skin, rice, beans, plantains, yuca, and the occasional marinated pork.”

 

Family History

 

His mother, age 73, has high cholesterol and diabetes. His father passed away of a heart attack at age 64. He has no siblings.

 

ROS:

 

Constitutional

 

Mr. Martin reports that he has gained 20 pounds in the past five years. He reports no malaise or fatigue.

 

Head, Ears, Eyes, Nose, and Throat

 

He reports no headaches or vision problems.

 

Lungs

 

He reports no shortness of breath or other breathing problems.

 

Heart

 

He reports no chest pain, palpitations, fainting, or murmurs.

 

Abdomen

 

He reports no abdominal concerns.

 

Genitourinary

 

He reports no urinary problems or erectile dysfunction.

 

Extremities

 

He reports no leg swelling, pain or cramping, or varicose veins.

 

Neurologic

 

He reports no weakness, tremors, or other neurologic concerns.

 

Physical Exam

 

Vital signs

 

Temperature is 37 °C (98.6 °F)

Pulse is 80 beats/minute

Respiratory rate is 18 breaths/minute

Blood pressure is 150/86 mmHg in right arm. 151/82 mmHg in the left arm.

Weight is 81.6 kg (180 lbs)

Height is 172.7 cm (68 in)

General: Well-appearing.

 

Eyes: No cotton wool spots, flare hemorrhages, exudates, arteriovenous nicking, or papilledema.

 

Neck: No thyromegaly, thyroid polyps, or masses. No bruits or jugular venous distension.

 

Lungs: Clear to auscultation bilaterally in all fields. No crackles, rhonchi, or wheezes.

 

Heart: Regular rate and rhythm. Regular S1 and S2. No murmurs, thrills, or rubs. Point of maximal impulse is in the left fifth intercostal space (normal).

 

Abdomen: No surgical scars or deformities. Normal bowel sounds in all quadrants. No bruits. No palpable tenderness or abdominal aortic pulses. No hepatosplenomegaly or other masses.

 

Extremities: No clubbing, cyanosis, or edema. 2+ pulses bilaterally in upper and lower extremities. Normal capillary refill. No venous stasis changes, erythema, or wounds.

 

Neurologic Exam: Alert and oriented x 3. Cranial nerves II – XII intact symmetrically. Normal gait and finger to nose testing. Normal proprioception. Reflexes 2+, symmetric bilaterally in upper and lower extremities.