Fred Macintyre is a 62 year old male who presents with a two month history of chest pressure/pain that radiates to cause “squeezing sensation” on his throat on a few occasions. He states that the pain is “probably a 5 or 6” out of 10. Episodes occur “maybe three or four times a week” with exertion or emotional upset and are relieved by rest on their own. He denies palpitations, lightheadedness, or syncope but had SOB and diaphoresis during one episode. Physical exam is positive for HTN (140/94), R carotid and L femoral bruits, no cardiac murmurs or edema. PMH includes HTN, elevated cholesterol levels treated with diet alone due to medication side effects, and > 50 packs-year history of smoking. FH is significant for both parents dying of CVD and now an older sister s/p MI.
Instructions: Answer the following questions. As you can see, I already have the primary and differential diagnosis.
Management Plan Template:
Primary Diagnosis and ICD-10 code: Also include any procedural codes.
3-5 Differential Diagnoses- Why? What made you select each one as a DDX? How did you rule out? This would be a good area to include references.
Primary Diagnosis: Stable Angina 120.9
- 1. Unstable Angina 120.0
- 2. Gastroesophageal Reflux Disease (GERD) K21.9
- 3. Esophageal Spasm K22.4
Additional laboratory and diagnostic tests: May be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patientâ€™s insurance carrier.
Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending to hospital, what orders would you write for a direct admit?
Therapeutic modalities: pharmacological and nonpharmacological management.
Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.
Patient education: Explanations and advice given to patient and family members.
Disposition/follow-up instructions: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist, or therapist.
Scholarly references (minimum of 3, timely, that prove this plan follows current standard of care).\\\”