Cardiovascular Part One Example
Setting: large rural clinic; family practice clinic that employs physicians and nurse practitioners You open the chart to review for your next patient, and you see it is Larry M. Larry is a 60 year-old African American male with a history of hypertension. You note he is not due for a follow up at this time, so you look at the chief complaint. CC: chest pain three days ago You enter the room and introduce yourself. Larry M. is sitting in the chair. You ask what brings him in today.Cardiovascular Part One Example Larry M. smiles, shaking his head and says “My wife made me come, I feel fine.” Three days ago Larry M. felt short of breath, had this heavy feeling in his chest, and he got kind of nauseous and sweaty. It lasted only about 3 minutes, and it has not happened again, but he does feel a little more tired. “It could be that I have not worked out since it happened.” PMHx: Reports general health as good. He had been feeling great since starting to work out and lost weight. Had lots of energy and felt great until this episode three days ago. Now he is a little concerned because he feels a little more tired when he works out.
Cardiovascular Part One He has not done as much strenuous running and has not worked out since the episode. Childhood/previous illnesses: chicken pox. Chronic illnesses: Hypertension- lifestyle changes recommended. Elevated cholesterol, lifestyle management was initiated. Surgeries: T and A, cholecystectomy, vasectomy Hospitalizations: None aside from surgeries listed above Immunizations: Does not receive the flu shot. Allergies: NKDA Blood transfusions: None Enjoys a beer or a glass of whiskey and the occasional cigar when playing poker with his buddies Current medications: None Social History: Married for 20 years, works as an architect. Family History: Parents are deceased. Father had lung cancer and mother died from complications of a stroke. Brother died at 44 from malignant melanoma. Other sister and brother are healthy. PE: Height: 5’8” weight: 220 pounds; BMI 33.5 vital signs:Cardiovascular Part One Example BP 146/90 P 70 Sao2 97% General: African American male in NAD. Alert, oriented, and cooperative. Pain: 0/10 at present Skin: Skin warm, dry, and intact. Skin color is light skinned brown, no cyanosis or pallor. HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. No AV nicking noted. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender Nose: Nares patent without exudate. Sinuses non-tender to palpation, Right-sided Deviation Throat: Oropharynx moist, no lesions or exudate. Teeth in poor repair, gums reddened and receding, filled cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Mild JVD in recumbent position Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored. No rashes or vesicles noted on chest. CV: Heart S1 and S2 noted, RRR, no murmurs, noted. No parasternal lifts, heaves, and thrills. Peripheral pulses equally bilaterally. PMI 5th ICS displaced 4cm laterally. No edema in lower extremities. Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted. Labs from 3 months ago: Total Cholesterol: 230 Ldl 180 Hdl 38 · EKG In office TODAY: ST depression Click here to access the EKG (Links to an external site.)Links to an external site. Discussion Questions:Cardiovascular Part One Example