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

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: Glenn Wright 70 yo male

 

Summary of most recent progress note:

 

Date: Four months prior

 

Chief Concern: Follow-up hypertension and hyperlipidemia

 

Subjective: Persistent stiffness in knees, but pain relieved with acetaminophen. Urine flow improved. Reports no exertional chest discomfort, decreased stamina, headaches, dizziness, or weakness. Occasionally omits diuretic and statin.

 

ROS: Occasional dizziness and decreased energy for 2 to 3 months. Decreased night vision. Occasional heartburn, stiff back, and knees. Reports no fever, syncope, headache, weight loss, abdominal discomfort, or change in bowel habits or stool.

 

Past Medical History: Essential hypertension, osteoarthritis, peptic ulcer disease, benign prostatic hyperplasia, hyperlipidemia, cataracts, and shingles. No surgery.

 

Family History: type 2 diabetes mellitus, hypertension, glaucoma.

 

Social History: Widowed for four years, retired railroad worker. Children: two daughters out-of-state and a son who lives nearby. Smoking: 1/2 pack per day resumed four years ago after ten-year abstinence. Alcohol: a single shot of whiskey most nights. Hobbies: quail hunting and fishing.

 

Medications: Hydrochlorothiazide 25 mg daily, amlodipine 10 mg daily, doxazosin 2 mg every evening, simvastatin 20 mg every evening, over-the-counter famotidine (Pepcid AC), acetaminophen.

 

Allergies: No known allergies.

 

Immunizations: H zoster, pneumococcal, Tdap, and influenza vaccines are current.

 

Objective: Blood pressure is 166/80 mmHg. No carotid bruits. Lungs: Clear. Heart: Regular rhythm. Rate in the 70’s beats/minute range, point of maximal impulse (PMI) laterally displaced.

 

Labs: Fasting lipid profile: total cholesterol 190 mg/dl, HDL 31 mg/dl, LDL 129 mg/dl, triglycerides 150 mg/dl.

 

Assessment: Hypertension – poorly controlled, hyperlipidemia – poorly controlled, osteoarthritis of the knees, benign prostate hyperplasia.

 

Plan: Follow up in 6 to 8 weeks.

 

Physical Exam

 

Vital signs:

 

Temperature is 37 C (98.6 F)

Pulse is 100 beats/minute

Respiratory rate is 16 breaths/minute

Blood pressure has no orthostatic changes

Weight is 80 kgs (176 lbs)

Height is 178 cm (70 in)

Pain is 0

Orthostatic Vital Signs

 

Position – Supine:

 

Pulse is 110 beats/minutes

Blood pressure is 166/82 mmHg

Position – Standing:

 

Pulse is 120 beats/minute

Blood pressure is 162/80 mmHg

Physical exam:

 

General: 70-year-old well-nourished man in no distress, alert, cooperative, and fully oriented.

 

TUG test: Normal

 

Head/Neck: Atraumatic, symmetric facies, no carotid bruit or neck vein distension.

 

Eyes: Normal visual acuity, pupils equal, round, reactive to light and accommodation (PERRLA), extraocular movements intact (EOMI), no nystagmus, normal visual fields, suboptimal fundoscopic exam secondary to cataracts, but no evidence of papilledema.

 

Ear/nose/throat: Unremarkable.

 

Chest: Normal respirations and lung fields.

 

Cardiovascular: Rate 118, irregularly irregular rhythm (not previously noted), no murmur, point of maximal impulse (PMI) 5th intercostal space laterally displaced 3cm.

 

Abdomen: Unremarkable.

 

Genitourinary: Deferred.

 

Musculoskeletal: Osteoarthritic knee changes. No apparent injury.

 

Neurological: No dysphonia or dysphagia, gag intact. No sensory or proprioceptive deficit. No Babinski, normal Romberg. FAST test: Symmetric smile. Muscle strength 4/4 in all limbs. No pronator drift. Able to repeat, “No ifs, ands, or buts” without slurring or difficulty.