C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure. Allergic RhinitisDepressionHypothyroidism Father died at age 49 from AMI: had HTNMother has DM and HTNBrother died at age 20 from complications of CFTwo younger sisters are A&W The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised. Zyrtec 10 mg daily Penicillin States that his overall health has been fair to good during the past year.Weight has increased by approximately 30 pounds in the last 12 months.States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.Denies any nausea, vomiting, diarrhea, or blood in stool.Self treats
for occasional right knee pain with OTC Ibuprofen.Denies any genitourinary symptoms. B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs. TMs intact and clear throughoutNo nasal drainageNo exudates or erythema in oropharynxPERRLAFunduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema Supple without masses or bruitsThyroid normalNo lymphadenopathy Mild basilar crackles bilaterallyNo wheezes RRRNo murmurs or rubs Soft and non-distendedNo masses, bruits, or organomegalyNormal bowel sounds Moves all extremities well No sensory or motor abnormalitiesCN’s II-XII intactDTR’s = 2+Muscle tone=5/5 throughout Develop an evidence-based management plan.Include any pertinent diagnostics.Describe the patient education plan.Include cultural and lifespan considerations.Provide information on health promotion or health care maintenance needs.Describe the follow-up and referral for this patient.Prepare a 3–5-page paper (not including the title page or reference page). Before finalizing your work, you should:be sure to (as displayed above); to make sure you have included everything necessary; andutilize and to minimize errors.Your writing Assignment should:follow the conventions of (correct grammar, punctuation, etc.);be , , and , as well as ;display and ; anduse format as outlined in the