Scenario: A 52-year-old male patient who is a house painter presents to the office reporting chronic fatigue
and “mild” chest pain. When he is painting, chest pain is relieved after taking a break. He reports that
the pain usually lasts 5 minutes or less and occasionally spreads to his left arm before subsiding. The
patient was last seen 3 years ago by you, and you recommended diet changes to manage mild
hyperlipidemia, but the patient has gained 30 pounds since that time. The patient’s medical history includes
anxiety, vasectomy, cholecystectomy, and mild hyperlipidemia. The patient does not smoke or use other
tobacco or nicotine products. The patient cares for his wife, who has multiple sclerosis and requires 24-hour
care. His daughter and grandson also live with the patient. His daughter assists with the care of his wife,
and his job is the major source of income for the family. The initial vital signs are blood pressure 158/78,
heart rate 87, respiratory rate 20, and body mass index 32. As part of the diagnostic work-up, an ECG, lipid
levels, cardiac enzymes, and C-reactive protein (CRP) are ordered. The patient reports that he does not
have time to “be sick” and says that he needs to take care of everything during this visit so he can return to
work and care for his wife.
What additional information should you obtain about the pain the patient is experiencing?
What additional physical assessments need to be completed for this patient?
What differential diagnoses should be considered for the patient?
Assuming that the in-office EKG did not indicate any abnormalities, how would you proceed to manage the
abnormal subjective and objective findings discovered during this visit? Include specific interventions for
each diagnosis in your treatment plan. Provide complete prescription details, follow up instructions, and
potential referrals.
What patient teaching will be incorporated into the visit to modify the patient’s risk factors?
Include the ICD 10 codes you would choose for each problem addressed and the Evaluation and
Management code expected for this visit. Keep in mind the length of time it has been since this patient has
been seen in the clinic.