2Chief ComplaintThe chief complaint is a brief statement of the reason why the patient consulted the physician, stated in the patient’s own words. In order to convey the patient’s symptoms accurately, medical terms and diagnoses are generally not used. The appropriate medical terminology is used after an appropriate evaluation (i.e., medical history, physical examination, laboratory and other testing) leads to a medical diagnosis.
3Chief Complaint“I just moved to town, and I’m here to see my new doctor for a checkup. I’m just getting over a cold. Overall, I’m feeling fine, except for occasional headaches and some dizziness in the morning. My other doctor prescribed a low-salt diet for me, but I don’t like it!”
4HPIThe history of present illness is a more complete description of the patient’s symptom(s). Usually included in the HPI are:• Date of onset• Precise location• Nature of onset, severity, and duration• Presence of exacerbations and remissions• Effect of any treatment given• Relationship to other symptoms, bodily functions, or activities (e.g., activity, meals)• Degree of interference with daily activities
5HPISam Street is a 62-year-old African-American male who presents to his new family medicine physician for evaluation and follow-up of his medical problems. He generally has no complaints, except for occasional mild headaches and some dizziness after he takes his morning medications.
6He states that he is dissatisfied with being placed on a low sodium diet by his former primary care physician. He reports a “usual” chronic cough and shortness of breath, particularly when walking moderate distances (states, “I’m just out of shape”).
7PMHThe past medical history includes serious illnesses, surgical procedures, and injuries the patient has experienced previously. Minor complaints (e.g., influenza, colds) are usually omitted unless they might have a bearing on the current medical situation.
8PMH Hypertension × 15 years Type 1 diabetes mellitus Chronic obstructive pulmonary disease, Stage 2 (Moderate)Benign prostatic hyperplasiaChronic kidney disease
9FHThe family history includes the age and health of parents, siblings, and children. For deceased relatives, the age and cause of death are recorded. In particular, heritable diseases and those with a hereditary tendency are noted (e.g., diabetes mellitus, cardiovascular disease, malignancy, rheumatoid arthritis, obesity).
10FHFather died of acute MI at age 71. Mother died of lung cancer at age 64. Mother had both HTN and DM.
11SHThe social history includes the social characteristics of the patient as well as the environmental factors and behaviors that may contribute to the development of disease. Items that may be listed are the patient’s marital status; number of children; educational background; occupation; physical activity; hobbies; dietary habits; and use of tobacco, alcohol, or other drugs.
12SHFormer smoker (quit 3 years ago; smoked 1 ppd × 28 years); reports moderate amount of alcohol intake. He admits he has been nonadherent to his low sodium diet (states, “I eat whatever I want.”) He does not exercise regularly and is limited somewhat functionally by his COPD. He is retired and lives alone.
13Meds:The medication history should include an accurate record of the patient’s current use of prescription medications, nonprescription products, and dietary supplements. Because pharmacists possess extensive knowledge of the thousands of prescription and nonprescription products available, they can perform a valuable service to the health care team by obtaining a complete medication history that includes the names, doses, routes of administration, schedules, and duration of therapy for all medications, including dietary supplements and other alternative therapies.
14Meds: Triamterene/hydrochlorothiazide 37.5 mg/25 mg po Q AM Insulin 70/30, 24 units Q AM, 12 units Q PMDoxazosin 2 mg po Q AMAlbuterol INH 2 puffs Q 4–6 h PRN shortness of breathTiotropium DPI 18 mcg 1 capsule INH dailySalmeterol DPI 1 INH BIDEntex PSE 1 capsule Q 12 h PRN cough and cold symptomsAcetaminophen 325 mg po Q 6 h PRN headache
15ALL:Allergies to drugs, food, pets, and environmental factors (e.g., grass, dust, pollen) are recorded. An accurate description of the reaction that occurred should also be included. Care should be taken to distinguish adverse drug effects (“upset stomach”) from true allergies (“hives”).
17ROSIn the review of systems, the examiner questions the patient about the presence of symptoms related to each body system. In many cases, only the pertinent positive and negative findings are recorded. In a complete ROS, body systems are generally listed by starting from the head and working toward the feet and may include the skin, head, eyes, ears, nose, mouth and throat, neck, cardiovascular, respiratory, gastrointestinal, genitourinary, endocrine, musculoskeletal, and neuropsychiatric systems.
18The purpose of the ROS is to evaluate the status of each body system and to prevent the omission of pertinent information. Information that was included in the HPI is generally not repeated in the ROS.
19ROSPatient states that overall he is doing well and just getting over a cold. He has noticed no major weight changes over the past few years. He complains of occasional headaches, which are usually relieved by acetaminophen, and he denies blurred vision and chest pain. He states that his shortness of breath is “usual” for him, and that his albuterol helps.
20He denies experiencing any hemoptysis or epistaxis; he also denies nausea, vomiting, abdominal pain, cramping, diarrhea, constipation, or blood in stool. He denies urinary frequency, but states that he used to have difficulty urinating until his physician started him on doxazosin a few months ago.
21Physical ExaminationThe exact procedures performed during the physical examination vary depending upon the chief complaint and the patient’s medical history. In some practice settings, only a limited and focused physical examination is performed. In psychiatric practice, greater emphasis is usually placed on the type and severity of the patient’s symptoms than on physical findings. A suitable physical assessment textbook should be consulted for the specific procedures that may be conducted for each body system. The general sections for the PE are outlined as follows:
22Gen (general appearance) VS (vital signs)—blood pressure, pulse, respiratory rate, and temperature.In hospital settings, the presence and severity of pain is included as “the fifth vital sign, weight and height are included in the vital signs section here, but they are not technically considered to be vital signs.Skin (integumentary)
23HEENT (head, eyes, ears, nose, and throat) Lungs/Thorax (pulmonary)Cor or CV (cardiovascular)Abd (abdomen)Genit/Rect (genitalia/rectal)MS/Ext (musculoskeletal and extremities)Neuro (neurologic)
24Gen:WDWN, African-American male; moderately overweight; in no acute distress.WDWN = Well-developed, well-nourished.
25VSBP 168/92 mm Hg (sitting; repeat 170/90), HR 76 bpm (regular), RR 16 per min, T 37°C; Wt 95 kg, Ht 6'2'‘BP = Blood Pressure.HR = Heart rate.Bpm = beat per minute.RR = Respiratory rate.T = Temperature.Wt = WeigtHt= Hight
26HEENTTMs clear; mild sinus drainage; AV nicking noted; no hemorrhages, exudates, or papilledema.TM = Tympanic membrane.AV = arteriovenous
27Neck:Supple without masses or bruits, no thyroid enlargement or lymphadenopathyLungs:Lung fields CTA bilaterally. Few basilar crackles, mild expiratorywheezing
28Heart: RRR; normal S1 and S2. No S3 or S4 RRR = Regular rate and rhythm.S = Sound.
29Abd: Soft, NTND; no masses, bruits, or organomegaly. Normal BS. NTND = Non-tender/non-distended.BS = Bowel sounds; breath sounds or blood sugar
34ECG ECHO (6 months ago): Normal sinus rhythm Mild LVH, estimated EF 45%:LVH = Left ventricular hypertrophy.EF = Ejection fraction.
35Assessment: Hypertension, uncontrolled Type 1 diabetes mellitus, controlled on current insulin regimenModerate COPD, stable on current regimenBPH, symptoms improved on doxazosin
36Problem Identification 1.a. Create a list of this patient’s drug-related problems, including any medications which may be contributing to the patient’s uncontrolled hypertension.
37DDIs: Significant - Monitor Closely triamterene + albuterol triamterene increases and albuterol decreases serum potassium. Effect of interaction is not clear, use caution. Significant - Monitor Closely.triamterene + salmeteroltriamterene increases and salmeterol decreases serum potassium. Effect of interaction is not clear, use caution. Significant - Monitor Closely.albuterol + salmeterolalbuterol and salmeterol both decrease serum potassium. Significant - Monitor Closely.
38albuterol + hydrochlorothiazide albuterol and hydrochlorothiazide both decrease serum potassium. Significant - Monitor Closely.salmeterol + hydrochlorothiazidesalmeterol and hydrochlorothiazide both decrease serum potassium. Significant - Monitor Closely.albuterol + salmeterolalbuterol and salmeterol both decrease sedation. Significant - Monitor Closely.albuterol and salmeterol both increase sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Significant - Monitor Closely.
39Minor albuterol + hydrochlorothiazide albuterol, hydrochlorothiazide. Mechanism: pharmacodynamic synergism. Minor or non-significant interaction. Hypokalemia.salmeterol + hydrochlorothiazidesalmeterol, hydrochlorothiazide. Mechanism: pharmacodynamic synergism. Minor or non-significant interaction. Hypokalemia.hydrochlorothiazide + insulin glarginehydrochlorothiazide decreases effects of insulin glargine by pharmacodynamic antagonism. Minor or non-significant interaction. Thiazide dosage >50 mg/day may increase blood glucose.
40Problem Identification 1.b. How would you classify this patient’s HTN (e.g., Prehypertension, Stage 1, or Stage 2), according to JNC 7 Guidelines?1.c. What are the patient’s known cardiovascular risk factors, and what is the patient’s Framingham risk score?1.d. What evidence of target organ damage or clinical cardiovascular disease does this patient have?
45Desired Outcome2. List the goals of treatment for this patient (including the patient’s goal blood pressure, according to JNC 7 Guidelines).
46Therapeutic Alternatives 3.a. What lifestyle modifications should be encouraged for this patient to achieve and maintain adequate blood pressure reduction?
47Therapeutic Alternatives 3.b. What reasonable pharmacotherapeutic options are available for controlling this patient’s blood pressure, and what comorbidities and individual patient considerations should be taken into account when selecting pharmacologic therapy for his HTN? How might Mr. Street’s HTN medications potentially affect his other medical problems?
48Optimal Plan4.a. Outline specific lifestyle modifications for this patient.4.b. Outline a specific and appropriate pharmacotherapeutic regimen for this patient’s uncontrolled hypertension, including drug(s), dose(s), dosage form(s), and schedule(s).
49Outcome Evaluation5. Based on your recommendations, what parameters should be monitored after initiating this regimen and throughout the treatment course? At what time intervals should these parameters be monitored?
50Patient Education6. Based on your recommendations, provide appropriate education to this patient.