Requirements:

Setting: large rural clinic; family practice clinic that employs physicians, physician assistants and nurse practitioners.

You open the chart to review for your next patient, and you see it is Lorene M. Lorene is a 60 year-old African American female with a history of hypertension and known documented metabolic syndrome following lifestyle changes per her request. You note she is not due for a follow up at this time, so you look at the chief complaint.

CC: Shoulder discomfort and SOB with exercise 3 days ago.

You enter the room and introduce yourself to Lorene who is sitting in the chair. You ask what brings her in today. She smiles, shaking her head and says "My daughter made me come, I feel fine. I am way too busy to be here today. Since my last visit, three months ago, I joined a gym and with the support of my daughter, we are going two days a week." However, three days ago Lorene felt short of breath while in dance class. She developed what she calls as "a discomfort" that radiated back and up between her shoulder blades while at the peak of her exercise routine. She also felt a little nauseous and sweaty. Once she stopped dancing, all symptoms resolved in about 3 minutes and they have not re-occurred.

PMHx: Reports general health as good. She has been trying to lose weight through exercise and avoiding processed foods. She admits that food is a large part of her background and heritage in social activities and so it is difficult to make healthy choices. She had been feeling great since starting to work out and has lost 2 inches around the abdomen. She describes having lots of energy until this episode three days ago.  Now she is a little concerned because she feels a little more tired than usual. She has not participated in anything strenuous and has not worked out since

Childhood/previous illnesses: chicken pox.

Chronic illnesses: Hypertension, Metabolic Syndrome, and Dyslipidemia.(Lifestyle management was initiated per patient preference) Gestational Diabetes with 3 pregnancies managed with Insulin

Surgeries: T and A, cholecystectomy

Hospitalizations: None aside from surgeries listed above

Immunizations: Does not receive the flu shot.

Allergies: Reports remote Hx allergy to metformin. Describes a GI disturbance.

Blood transfusions: None

Current medications: None. Stopped Lisinopril one month ago as she read that it can cause a cough as one if its side effects. Prefers to get the BP under control with diet and exercise.

Social History: Married for 20 years. Children are grown and have moved out of the house but all live locally and are close to their parents. Lorene works full time as a CEO of a successful marketing company and travels often for work. She eats out a lot while entertaining business clients. She enjoys beer and wine and the occasional "social" cigarette when she gets together once weekly with her girlfriends.

Family History: Parents are deceased. Father had lung cancer and mother died from complications of a stroke due to complications of diabetes type 2. Brother died at 44 from malignant melanoma. Other sister and brother are healthy but they also have diagnoses of metabolic syndrome.

PE:

Height: 5’8" weight: 220 pounds; BMI 33.5 vital signs: BP 146/90 P 70 Sao2 97% Random glucose finger stick in office: 130mgs/dl

General: African American female 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. Trace edema in lower extremities.

Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted.

Labs from 3 months ago:

AIC 6.4%

Fasting glucose 135mgs/dl

Total Cholesterol: 230

Triglycerides 180mgs/dl
Ldl 180
Hdl 38

EKG today in the office

EKG ST Depression

Week 3 Discussion Questions:

1. What Leads Demonstrate the ST Depression?
2. Is Lorene Hypertensive per ACA 2017 Guidelines? Compare the ACA guidelines to JNC 8 guidelines and discuss what treatment you recommend for her BP and why.
3. What is the Primary diagnosis causing Lorene’s chest pain? Include ICD 10 codes (no differentials)
4. What other secondary diagnoses does Lorene have that should be addressed? (Include the rationale and a reference for your diagnoses)
5. Design a treatment plan and discuss how each intervention is applicable to Lorene’s case. Consider the following interventions:
Labs
Durable Medical Equipment Diagnostic tests- discuss the goal/purpose
Any consultation with outside providers/services
Medications- discuss why you chose each specific medication
Referrals- who and why
Follow up- why and when
Education- specific and measureable
Lifestyle Changes- specific to her cultural preferences, values and beliefs


 

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Requirements:

Anxiety and depression are the most common psychiatric problems you will encounter in your primary care practice.

Review this case study

HPI: BT, 50-year-old Caucasian male presents to office with complaints of “no energy and staying in bed all day.” These symptoms have been present for about 4 months and seem worse in the morning. It is hard to get out of bed and get the day started because he does not feel rested when he gets up in the morning.  BT reports “deep sadness & heartache over the loss of his wife”. States” I really don’t feel like making plans or going out”.  He tries to make plans with family or friends once a week, but it can be really exhausting because everyone asks about how he is handling the loss. Reports he also has difficulty completing projects for work, he cannot stay focused anymore. He reports not eating regularly and has lost some weight. BT has been a widower for 10 months. His wife died unexpectedly, she had an MI. His oldest daughter has a 2-year-old daughter, she asked him to babysit a couple of times, which he thought would help with the loneliness, but the care of his granddaughter seems overwhelming at times. Rest, evening walks, & lifting weights 2 days a week help him feel better. At this time, he does not want to do any activities or exercise, it seems like too much effort to get up and go. He has not tried any medications, prescribed or otherwise. He reports drinking a lot of coffee, but that does not seem to help with his energy levels. 
Current medications: Tylenol PM about once a week when he can’t sleep, does not help.
NKDA. 

PMH: no major illnesses. Immunizations up to date.  COVID Vaccinated.

SH: widowed, employed part time as a computer programmer. Drinks 1 beer almost every night. No tobacco use, no illicit drug use. Previously married 25 years ago, reports a passive aggressive, abusive relationship that ended in divorce. The judge gave full custody of his children to his ex-wife. The last time he saw his son was10 years ago. He lives in another stated. He sees his daughter 1-2 times a month. He would like to talk to his son but he is concerned the relationship cannot be repaired because he moved out during the divorce.

FH: Parents are alive and well. Has a daughter 20 and a son 18.

ROS 

CONSTITUTIONAL: reports weight loss of 4-5 pounds, no fever, chills, or weakness reported. Daily fatigue.  

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. 

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. 

RESPIRATORY: No shortness of breath, cough or sputum. 

GASTROINTESTINAL: Reports decreased appetite for about 4 months. No nausea, vomiting or diarrhea. No abdominal pain or blood. 

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. 

GENITOURINARY: no burning on urination.  

PSYCHIATRIC: No history of diagnosed depression or anxiety. Reports history feeling very sad and anxious about loss of wife. Sad about not speaking to his son. Did not seek treatment. He started to feel better about the loss of his wife after 6 months but the grief and depression has returned.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia 

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

Discussion Questions: 

Research screening tools for depression and anxiety. Choose one screening tool for depression and one screening tool for anxiety that you feel are appropriate to screen BT.
Explain in detail why each screening tool was chosen. Include the purpose and time frame of each chosen tool.
Score BT using both of your chosen screening tools based on the information provided (not all data may be provided, those areas can be scored as not present). Pay close attention to the listed symptom time frame for your chosen assessment tool.  In your response include what questions could be scored, and your chosen score.  Interpret the score according to the screening tool scoring instructions. Assume that any question topics not mentioned are not a concern at this time.
Identify your next step for evaluation and treatment for BT. Remember to consider both physical and mental health differential diagnoses when answering this question. (2-3 sentences).
What medication or treatment is appropriate for BT based on his screening score today? Provide the rationale. Any medications should include the medication class, mechanism of action of the medication and why this medication is appropriate for BT. Include initial prescribing information.  
If the medication works as expected, when should BT expect to start feeling better?
DISCUSSION CONTENT

Category

Points

%

Description

Application of Course Knowledge  

21  

30

Initial discussion post includes the following:

1) two screening tools chosen- 1 for depression, one for anxiety

2) Student explains rationale for both screening tool choices (2-3 sentences)

3) both screening tools are scored using provided case study information only AND scores are interpreted using tool scoring guidelines.

4) Next steps for treatment includes physical health diagnoses and suggested necessary diagnostics

5) Medication choice is listed. Rationale includes medication class, mechanism of action and initial prescribing information and education to include side effects and when BTshould notice efficacy.

Support from Evidence-Based Practice (EBP) 

14 

20 

1. Discussion post is supported with appropriate, scholarly sources; AND  

2. Sources are published within the last 5 years ; AND 

3. Reference list is provided and in-text citations match; AND 

4. Includes a minimum of one scholarly reference, textbook is not used

Interactive Dialogue 

21 

30 

1. Student provides a substantive* response to at least one topic-related post of a peer; AND 

2. Student provides a substantive response to any faculty questions asked regarding the initial student post.  

3. Evidence from appropriate scholarly sources are included;  

4. Submits a minimum of two posts on two different days. 

(*) A substantive post adds new content or insights to the discussion thread and information from student’s original post is not reused in peer or faculty response 

56

80%

Total CONTENT Points= 56 points

DISCUSSION FORMAT

Category

Points

%

Description

Organization 

7

10 

1) Discussion is presented in a logical format, AND 

2) Responses are in sequence with the listed bullet points AND 

3) The discussion response is understandable and easy to follow AND

4) All responses are relevant to the discussion  topic. 

 

Grammar, Syntax, Spelling & Punctuation 

7

10 

Discussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors* 


 

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