PBL Case Discussion: Cardiovascular

• Part One (graded)

Setting: large urban city

Family practice clinic that employs physicians and nurse practitioners

Part 1: It’s another busy day at the clinic. You open the chart to review for your next patient, and you see it is Sean M. Sean is a 52 year-old white male with a history of hypertension. He was taken off HTN meds at last visit almost 3 months ago. You note he is not due for a follow up at this time, so you look at the chief complaint.

Discussion Questions Part One:

1. What further questions do you have for Sean at this visit?
2. What is your differential diagnosis list for this visit thus far with rationale?
3. Based on your differential diagnoses list, identify what body systems you’d examine along with pertinent positive/negatives in each system and any diagnostic tests you would like to perform?

• Part Two:

Based on JNC 8 guidelines, is Sean hypertensive?

In office EKG shows ST depression

What are your diagnoses with ICD 10 codes for Sean? Include the rationale and a reference for your diagnoses.

Plan for each primary diagnoses based on one current evidence-based journal article.

Further diagnostic work-up not included above

Medications

Referrals

Conservative measures

Patient education

Follow-up plan

• SOAP Note

S.M., 52 yo, M, Caucasian

S.

CC: chest pain 3 days ago

HPI: Sean says his wife made him come in, even to know he feels fine. Three days ago he felt short of breath, had a heavy feeling in his chest, and got kind of nauseous and sweaty. It lasted only 3 minutes, and 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.”