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Original Question
Case Study #1 CC: Recent onset morning headache, chest tightness HPI: 42 yr old African American male who presents with BP 168/92 and morning headaches. Reports headaches upon arising approximately 2 x per week. This morning prompted his coming to the office for evaluation as he was experiencing some lightheadedness and chest tightness that resolved following his shower. He has never been told that his blood pressure was high, but he has not been seen in the office for approximately 6 years. His last visit was for bronchitis and treatment with antibiotics. Past medical/surgical history: Unremarkable Family history: Father deceased, age 51, acute MI Brother deceased, age 50, acute MI following abdominal aortic aneurysm surgery 4 other siblings, all in good health Social history: Dealing with several life issues including death of a child and a reduction in work hours at a local manufacturing plant. Smokes 2 packs of cigarettes per day, varied in volume over the last 44 years, leads a sedentary life outside of work, and is overweight at 6’2″, 255lbs (BMI 33). Overall, he feels he is in good health. Married and has 3 remaining children: 12, 15, and 17. Oldest son was killed in a car accident 2 months ago. Moderate alcohol consumption reported at 2-3 beers, 4-5 times per week. He drinks more heavily on the weekends. Active in the church with his wife. He is a HS graduate and makes approximately 50K/yr. His wife works FT and supplements household income to total approximately 90K/yr. For the last 3 months, work hours have been reduced with implemented mandatory furlough days, resulting in household spending to be significantly reduced. There has been no difficulty meeting basic financial obligations such as housing, food, electric, gas, water, car payments, cell phone bills, and insurance. Medication history: Takes no prescription medications. Does take an aspirin and multivitamin daily Allergies: NKA, but does report being lactose intolerance, which he manages with diet ROS: See HPI, no additional information at this time Exam: VS: T: 98.2 F, oral, BP on arrival: left arm sitting, 188/92, after 20 min, repeat BP left arm sitting, 180/90. P: 94, R: 20 Gen: A & O, appears older than stated age, frowning HEENT: unremarkable Neck: No lymphadenopathy Skin: Warm and dry Respiratory: Lung sounds vesicular over peripheral fields; harsh, bronchial breath sounds in upper lobes bilaterally; moist cough audible; no adventitious breath sounds. Cardiovascular: No jugular venous distention at 30 degree elevation. Heart sounds strong +3/4; grade 2/6 systolic murmur at left sternal border, 5th intercostal space. Abdominal and peripheral vascular assessments unremarkable; pedal and post tibial pulses +2/4+. Abdomen: Tender over RUQ. Tympany predominates. Liver border WNL, spleen and kidneys not palpable. Neuromuscular: Cranial nerves intact, Romberg sign negative; gait relaxed and symmetrical; no pronator drift; FROM to all extremities Differential: Please list the diagnoses to include in the differential, including rationale and a source to support your decision. (Hint: Consider reasons why someone would have a morning headache apart from the elevated BP) (5 pts) LABS/Tests: What labs/tests would you order to work through the differential? (Hint: Think about all of the symptoms that he presented with in clinic and what labs/test are needed to contribute to arriving at the correct diagnosis and r/o the others) (5 pts) Assuming your tests and labs come back normal apart from mild hyperlipidemia, what is your diagnosis and why? (5 pts) What is the plan for treatment? (Remember, if you prescribe medication, you will need to write out all parts of the prescription including number dispensed and refills)(15 pts) What is the plan for follow-up care (Hint: In addition to returning for follow-up, is there anything the patient should be monitoring at home that he should bring back to the visit?) (10pts) Are there any referrals needed? (5pts) Does it make a difference in your medical management decision if this patient were a female? (5pts) **Bonus Points** (5pts): What education might you provide to this patient? (Must include 5 points of education explained in the way you would explain it to the patient to receive full credit, worth 5 points extra credit, please support with evidence)
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