For this Case Study Assignment, you will analyze an i-Human simulation case study about an adult patient with a gastrointestinal condition. Based on the patient’s information, you will formulate a differential diagnosis, evaluate treatment options, and then create an appropriate treatment plan for the patient.
Assessment/ management plan. You must have a problem statement, Dx and diff. Dx with appropriate codes, medications ordered (with dosing), treatment plan with SDOH and Health promotion, patient education, f/u education. And references to support aspects of the management plan (such as medications, dx, treatment, etc..)
Patient is a 58-year-old male, he is 216 pounds, BMI 29.3, height 72 inches tall, AO4.
Patient is here for burning chest discomfort. The patient’s chest pain will come up out of his sleep.
Vitals temp- 98.6F, pulse 74, BP (left) 132/82, (right) 130/80, respiration 13, 02-98%
Patient works in airplane maintenance
Patient Mary second wife, 13 years. Stepdaughter is 14 years of age.
-Chest pain- mid- sternum
-Chest pain 4.5-5 out of 1-10 pain scale
-The chest pain moves up into my neck just above Adams apple
patient stay he’s had a few recent episodes of chest pain, but this is all new
Chest pain last 30 minutes, maybe longer
Patient has had 4 episodes of chest pain
Patient drinks, alcohol, one drink after dinner, but not every night. Sometimes a Jack Daniels. Patient last drink was 10pm last night
Patient drinks, black coffee for breakfast. He’s usually eating out for lunch, burgers, or fast food. In the afternoon break is coffee, sometimes a sweet with it. Dinner is home-cooked and healthy.
No issues with fatigue, sleeping or night sweats or fevers
No hx of heart burn
Patient denies difficulty breathing. When the pain starts, he finds his self taking smaller breaths, but if he takes a big breath, it feels the same, no real change with breathing
Patient denies problems with nervousness, depression, memory, loss, or mood changes. He states he is a bit stressed with money worries in regards to college for his daughter
No allergies
Medical history- Patient has high blood pressure and is over weight. Patient is on Lopressor 50mg po QD
Patient has not taken anything for his symptoms
Up-to-date on vaccines
Father had MI in his 50s and 60s, died of CVA at age 85.
Mother is alive and well at age 77. Mild hypertension and osteoporosis.
Sister age 52 no medical issues
Paternal grandfather died of MI at 65
Colonoscopy at 56 was supposed to be going to Weight Watchers for weight reduction, but has poor compliance, was supposed to be exercising
