Cardiovascular case study

Mr. H is a 60-year-old male presenting to his primary care office with chest pain. He has a past medical history of well-controlled HTN, obesity and diabetes. Reports he has been having this pain on and off for the past 4 months. Says it feels like squeezing and pressure to center of chest and Difficulty breathing with activity especially stairs. This will resolve with resting for a few minutes. Reports also will feel the pressure when stressed. Reports Difficulty breathing with exertion, and at night Also states is “retaining water” in his legs which is new. Has not taken any medications for the pain. Reports has had had a diaphoresis “a few times” with the pain. Denies association with fatty or spicy foods.
Current Medications: Metformin, ASA and Lisinopril
Physical exam: Vital signs: 98.6/82/16/ BP 126/82, SPO2 94% on room air. Unremarkable except for peripheral neuropathy related to diabetes and +1 pitting edema bilaterally from knees to feet. In office ECG is remarkable only for evidence of left ventricular hypertrophy with strain.

Include:
1. Identify the Problem
Constructs a complete problem list that consists of Chief Complaint, Other acute symptoms, Chronic active problems, significant past medical history, significant family /social history, abnormal physical exam findings and preliminary abnormal lab findings.

2. Frame the differential diagnoses
Uses anatomic framework and/or organ/system framework and/or pathophysiologic framework to frame the differential diagnoses. The list addresses the problem list from the first step/criteria effectively. The differential diagnoses list(s) are comprehensive for each problem elicited.

3. Organize the differentials
The differential diagnoses are organizedin clinically useful subgroups. Addresses all the differential diagnoses.

4. Use Pivotal Points to limit differentials
Uses pivotal points such as acute vs. chronic, unilateral vs. bilateral etc. tolimit the differential diagnoses list. The final list is patient specific

5. Explore patient specific differentials: Need 3
Explores the patient specific differential diagnoses list using history,physical exam findings, risk factors, associated symptoms etc. The patient specific differentials list is comprehensive containing at least 3 potential diagnoses, with appropriate consideration of multisystem involvement/broad range etiology, is detailed to include supportive rationale for each differential diagnosis. Rationale is evidenced basedusing scholarly sources and includes pertinent patient specific information.

6. Rank the differentials to develop hypotheses
Ranks the differentials using the results of the exploration; Uses evidence from literature to accurately identify the leading differential diagnosis, must not miss differential diagnosis, and alternative diagnosis

7. Summarize Evidence based diagnostics and treatment plan for the first three differentials
Evidence based diagnostics and treatment plan is appropriate for the diagnosis and accurately addresses the problem identified. Evidence based diagnostics and treatment plan includes plans for evaluation/follow-up care as appropriate.Evidence based diagnostics and treatment plan is individualized to the patient’s age and development, culture,religion, family,environment,education, and/or anyother unique concerns uncovered in assessment. Use of evidence is displayed within supportive comprehensive rationale for each intervention.

8. Demonstrate appropriate and effective written communication.
Demonstrates Scholarly writing, APA style Formatting
Documentation is clear and well organized.Appropriate medical terminology is used. Redundant (repetitious)words, phrases, and other distracting information is omitted. Format follows a standard. Narratives have a logical flow.Submission is free of errors in scholarly tone, style, and APA formatting.

Scholarly References only no older than 5 years. No APA errors.

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