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Adopted from UNSOM CPS Case CPSI-010 Edgar Campbell

Contributing Faculty:

Michael Bloch, MD

Violeta Mutafova-Yambolieva, MD, PhD

Presenting Faculty: Michael J Bloch, MD

PART 1 (Presented after Introduction Monday at 8am)

CC: The patient is a 65 year-old Caucasian male referred to the Internal Medicine

Clinic with a chief complaint of “my blood pressure is too high.”

HPI: Mr. Campbell has had a diagnosis of hypertension for 20 years and has been on medication for about 12 years. He is currently taking HCTZ 25 mg daily and Atenolol 100 mg daily. He states that while he has had some elevated readings his doctors usually tell him that his BP is “OK.” Three weeks ago he was seen in Urgent Care because of a cold and his BP was found to be 190/110. Lisinopril 40 mg daily was added. Ten days later he was seen again and his BP was still elevated so amlodipine 5 mg daily was added. He has no headaches, chest pain, or complaints of confusion. He describes good adherence with his medications. He does not measure his BP at home. He denies any known use of stimulants anti-inflammatories or illicit drugs.

PMH: Carotid atherosclerosis with left carotid endarterectomy 4 years ago

Coronary artery disease with percutaneous coronary intervention 2 years

ago

Hypertension

Dyslipidemia

Gastro-esophageal reflux (GERD)

Medications:

Nitroglycerine SQ PRN for chest pain.

Hydrochlorthiazide (HCTZ) 25 mg PO daily

Lisinopril 40 mg. PO daily

Amlodipine 5 mg PO daily

Aspirin 81mg PO daily

Clopidogrel 75 mg daily

Lovastatin 20 mg PO daily

Family History:

Father died in automobile accident when patient was a child

Mother had hypertension and died at age 67 of a stroke.

Social History:

Was factory worker – now disabled.

Stopped smoking 4 years ago following diagnosis of CAD. Smoked 1-2 packs a day for 40 years prior to that.

Alcohol -one or two beers a week.

Wife died 6 years ago, lives alone, has no children. Spends most of his time watching television or playing cards with friends.

Review of Symptoms:

General: Denies fever, chills and weight loss, or difficulty sleeping.

HEENT: Denies headache, vision changes, hearing changes.

Respiratory: No cough or shortness of breath

Cardio: No chest pain or palpitations; no claudication; +occasional ankle swelling

GI: Denies nausea, vomiting, constipation, or diarrhea

GU: Denies hematuria, polyuria or other issues

Musculoskeletal: No joint pain or myalgias

Neurological: no focal weakness, change in mentation, strength or sensation

Mood: No depression or anxiety

Physical Exam:

Vitals:

Weight : 205 lbs.

Height : 5’9”

BP : 225/122

Pulse 80 regular

RR : 14

BMI 30.3

Waist Circumference 42”

General: Somewhat obese white male in no acute distress

Head: Normocephalic and atraumatic; Fundoscopic exam – moderate AV nicking.

Neck: No cervical bruits.

Well healed left neck incision

Chest: normal respiratory expansion

Lungs: Clear without wheezes or rales

Cardiovascular: Jugular venous pressure normal. Regular rate; normal S1 and S2 and no murmurs. PMI laterally displaced. Lower extremity pulses full

Abdomen: No masses or organomegaly. Loud bruit audible in left flank.

Extremities: No edema, pulses full.

Skin – no xanthomas or rash

Neuro : clear mentation; no pronator drift; Cranial nerves intact; gait normal;

Affect :normal.

LAB

BUN 18 mg/dL (8-20)

Creatinine 1.4 mg/dL (0.7-1.3)

eGFR 52 ml/min/1.72m2 (>60)

Total Cholesterol 244 mg/dL (150-199)

HDL-C 35 mg/dL (>40)

LDL-C 118 mg/dL ( ................
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