Family Medicine

56 year old man presents to clinic for his HME

Julie Blaszczak on Jan 15, 2016

Mr. B is a 56 year old white man who presents to your family medicine clinic as a new patient for his health maintenance examination.  He reports that he is new to the area as he just switched jobs.  For his new employer-provided health insurance, he says that he has to have a complete history and physical done by a physician.  He also reports that the paperwork states that his cholesterol must be checked, so he recently visited an outside lab to have that done.  He has brought in those results for you (see below).  You welcome him to the clinic, and as you go through his medical history, you discover the following:

Past Medical History: 

- Hypertension

Health Maintenance:

- Colonoscopy: Unremarkable (at age 50)

- Immunizations: Up to date

Past Surgical History:

- Appendectomy (as a child)

Medications:

- Lisinopril 20mg qday

Allergies: NKDA

Family History:

- Father passed away from complications of a stroke at age of 88.

- Mother still living.  She has psoriasis and high cholesterol.

- Two younger brothers with hypertension.

Social History: Mr. B lives in Dexter, MI with his wife.  He is an electrical engineer, and he sits during most of the day.  He and his colleagues go out to eat at either the local diner or one of the fast food restaurants nearby for lunch.  He enjoys golf during the summer, but has difficulty finding activites to do during the winter.  He says that the only exercise he gets is the 5 minute walk from the car to the front door of his job because of his busy work schedule.  He drinks 1-2 glasses of whiskey per week.  He is a former smoker (10 pack-years).  He denies illicit drug use.  He is only sexually active with his wife.


You also perform a physical exam which reveals the following:

Vitals: T 98.6F, HR 84, BP 137/88, BMI 31

General: Well-appearing older gentleman in NAD

Cardio: Regular rate and rhythm, normal S1/S2, no rubs, murmurs, or gallops, strong peripheral pulses

Pulm: CTAB, no rales, rhonci, or wheezes

Abdominal: Normal BS, nontender, nondistended, no palpable masses, no hepatosplenomegaly (note: examination difficult due to size of abdomen)

Neuro: A&Ox4, symmetric and normal tone, strength, and sensation, DTR 2+ throughout

MSK: Able to move all four extremeties without difficulty

Skin: Palmar aspects of hand appear dry bilaterally, otherwise unremarkable

Psych: Appropriate mood and affect


You take a look at his paperwork and see that he had a (fasting) lipid panel drawn:

Total Cholesterol 253

HDL 50

LDL 155

Triglycerides 240

You recall that the American College of Cardiology and American Heart Association developed new guidelines in 2013 for the treatment of dyslipidemia in regards to reducing atherosclerotic cardiovascular disease (ASCVD), and you set out to determine if Mr. B needs treatment.

Mr. B is a 56 year old white man who presents to your family medicine clinic as a new patient for his health maintenance examination.  He reports that he is new to the area as he just switched jobs.  For his new employer-provided health insurance, he says that he has to have a complete history and physical done by a physician.  He also reports that the paperwork states that his cholesterol must be checked, so he recently visited an outside lab to have that done.  He has brought in those results for you (see below).  You welcome him to the clinic, and as you go through his medical history, you discover the following:

Past Medical History: 

- Hypertension

Health Maintenance:

- Colonoscopy: Unremarkable (at age 50)

- Immunizations: Up to date

Past Surgical History:

- Appendectomy (as a child)

Medications:

- Lisinopril 20mg qday

Allergies: NKDA

Family History:

- Father passed away from complications of a stroke at age of 88.

- Mother still living.  She has psoriasis and high cholesterol.

- Two younger brothers with hypertension.

Social History: Mr. B lives in Dexter, MI with his wife.  He is an electrical engineer, and he sits during most of the day.  He and his colleagues go out to eat at either the local diner or one of the fast food restaurants nearby for lunch.  He enjoys golf during the summer, but has difficulty finding activites to do during the winter.  He says that the only exercise he gets is the 5 minute walk from the car to the front door of his job because of his busy work schedule.  He drinks 1-2 glasses of whiskey per week.  He is a former smoker (10 pack-years).  He denies illicit drug use.  He is only sexually active with his wife.


You also perform a physical exam which reveals the following:

Vitals: T 98.6F, HR 84, BP 137/88, BMI 31

General: Well-appearing older gentleman in NAD

Cardio: Regular rate and rhythm, normal S1/S2, no rubs, murmurs, or gallops, strong peripheral pulses

Pulm: CTAB, no rales, rhonci, or wheezes

Abdominal: Normal BS, nontender, nondistended, no palpable masses, no hepatosplenomegaly (note: examination difficult due to size of abdomen)

Neuro: A&Ox4, symmetric and normal tone, strength, and sensation, DTR 2+ throughout

MSK: Able to move all four extremeties without difficulty

Skin: Palmar aspects of hand appear dry bilaterally, otherwise unremarkable

Psych: Appropriate mood and affect


You take a look at his paperwork and see that he had a (fasting) lipid panel drawn:

Total Cholesterol 253

HDL 50

LDL 155

Triglycerides 240

You recall that the American College of Cardiology and American Heart Association developed new guidelines in 2013 for the treatment of dyslipidemia in regards to reducing atherosclerotic cardiovascular disease (ASCVD), and you set out to determine if Mr. B needs treatment.

370  views

  0 likes

      0 comments