Description
Essay Elements:
One to three pages of scholarly writing in paragraph format, not counting the title page or reference page
Brief introduction of the case
Identification of the main diagnosis with supporting rationale
Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out
Diagnostic plan with supporting rationale or references
A specific treatment plan supported by recent clinical guidelines
Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric.
Patient Name: Jose Martin 54 yo male
Past Medical History
Mr. Martin reports no history of hypertension, hypercholesterolemia, or diabetes. He reports no history of kidney disease, eye problems, peripheral vascular disease, heart disease, or strokes. No history of gout or arthritis. His last vaccinations were over 10 years ago, and he has not had any preventive services for his age. He reports no other medical problems.
Medications
None. Does not use complementary or herbal remedies.
Past Surgical History
None.
Social History
Mr. Martin speaks English and Spanish. He is married to his wife and has one daughter, age 16. He and his family moved here from the Dominican Republic 10 years ago. He works as a taxi driver for 12-hour shifts, six days a week. His wife works as a seamstress. They are both uninsured. His daughter gets her medical care in her high school clinic. He and his family live in a two-bedroom apartment near the clinic. He is sexually active with his wife only. He does not drink alcohol or use recreational drugs. He does not smoke. The patient has good emotional support from his family and friends. He admits to occasional financial stressors, but his family is never short of food or clothing. However, his daughter may be going to college soon and his rent continues to increase annually, which worries him.
Diet History
Mr. Martin states that he eats a lot of fast food during his long and busy taxi shifts. He eats better when he is at home. His wife makes “chicken without the skin, rice, beans, plantains, yuca, and the occasional marinated pork.”
Family History
His mother, age 73, has high cholesterol and diabetes. His father passed away of a heart attack at age 64. He has no siblings.
ROS:
Constitutional
Mr. Martin reports that he has gained 20 pounds in the past five years. He reports no malaise or fatigue.
Head, Ears, Eyes, Nose, and Throat
He reports no headaches or vision problems.
Lungs
He reports no shortness of breath or other breathing problems.
Heart
He reports no chest pain, palpitations, fainting, or murmurs.
Abdomen
He reports no abdominal concerns.
Genitourinary
He reports no urinary problems or erectile dysfunction.
Extremities
He reports no leg swelling, pain or cramping, or varicose veins.
Neurologic
He reports no weakness, tremors, or other neurologic concerns.
Physical Exam
Vital signs
Temperature is 37 °C (98.6 °F)
Pulse is 80 beats/minute
Respiratory rate is 18 breaths/minute
Blood pressure is 150/86 mmHg in right arm. 151/82 mmHg in the left arm.
Weight is 81.6 kg (180 lbs)
Height is 172.7 cm (68 in)
General: Well-appearing.
Eyes: No cotton wool spots, flare hemorrhages, exudates, arteriovenous nicking, or papilledema.
Neck: No thyromegaly, thyroid polyps, or masses. No bruits or jugular venous distension.
Lungs: Clear to auscultation bilaterally in all fields. No crackles, rhonchi, or wheezes.
Heart: Regular rate and rhythm. Regular S1 and S2. No murmurs, thrills, or rubs. Point of maximal impulse is in the left fifth intercostal space (normal).
Abdomen: No surgical scars or deformities. Normal bowel sounds in all quadrants. No bruits. No palpable tenderness or abdominal aortic pulses. No hepatosplenomegaly or other masses.
Extremities: No clubbing, cyanosis, or edema. 2+ pulses bilaterally in upper and lower extremities. Normal capillary refill. No venous stasis changes, erythema, or wounds.
Neurologic Exam: Alert and oriented x 3. Cranial nerves II – XII intact symmetrically. Normal gait and finger to nose testing. Normal proprioception. Reflexes 2+, symmetric bilaterally in upper and lower extremities.
