Resident Instructions

Open Resident
Instructions

 


 
 
CLINICAL PERFORMANCE EXAMINATION (CPX)

 

Station Length: 20 minutes maximum

Patient Name: John Harrison

Resident Instructions:

John Harrison is an 80 year old man with hypertension, hyperlipidemia, type 2 diabetes, mild renal failure and mild CHF. One month ago you saw him for a general physical exam (including blood work). At that time he was feeling fatigued on exertion.

BP 154/90, WT 92 kg and other vitals stable. His exam showed loss of protective sensation in his feet to the monofilament test but was otherwise normal. HgA1c 8.4, TCHOL 180, TG 135, HDL 32, LDL 130, creat 1.4 and the rest of chemistry and CBC normal.

Echo showed no change from previous – mild CHF with LVEF 40% and no valvular abnormality. Patient has a colonoscopy scheduled for next month. 2 normals in past – the last 12 years ago. Patient had a flu shot this year and got his Pneumovax at 65 years of age. You increased his Lisinopril from 10-20 mg and doubled his Glucotrol XL to 10 mg twice daily.

He is coming to see you because he has had 2 recent falls and is overall feeling less robust than normal.

Today his weight is 91.5kg and BP 110/80, RR18, HR 72, temp 37.1.
Chronic bilateral foot pain 2/10.

You review the patient’s last note which reveals the following:

7/10/09

Reason for visit: Preventive visit

PMHX:

Bilateral hearing impairment (>20 years)
Hypertension (30 years)
Hyperlipidemia (17 years)
Type 2 Diabetes Mellitus (15 years) with retinopathy
Chronic kidney disease (12 years)
CHF with EF 40% on echo 2009

Past Hospitalizations:        

Pneumonia 2004
Inguinal hernia repair 1990

Medications:

Lisinopril 20 mg daily
Metformin SR 1000 mg 2 tabs daily
Glipizide XL 10 mg twice daily
Lipitor 10 mg daily
Lasix 20 mg daily
Baby Aspirin daily

Social Hx :

Retired farmer
Lives with wife who helps with meds – children live away, but involved
Lives in 1 floor bungalow
Likes to walk
Etoh – 3 beer/wk
Tobacco – 45 pack years. Quit 15 years ago.

Family Hx:

m. d. 82 – ‘heart problems”
f. d. 83 – lung ca, smoker
brother. 84 – htn, lipids, colon cancer – doing well
sister. 78 – healthy
2 sons, 5 grandchildren all healthy

Preventive Health:

Colonoscopy normal x2 (last 2005)
See ophthalmologist yearly
Pneumovax at age 65
Flu shot yearly

ROS:

Fatigue, decreased exercise tolerance
No chest pain, SOB, cough, leg swelling, weakness. No focal symptoms. Denies depression.

PE:

Elderly man NAD. BP 160/92. HR 76. RR 16. T 36.4
HEENT: PERLA, EOM normal, OP normal, TM normal. No carotid bruit. No LAD. Thyroid normal
Chest: Clear
CVS: RRR no RMG
Abd: Normal. No mass or HSM
Extrem: No edema. Decreased sensation to mid-calf in bilat lower extremities on microfilament testing.
PPP. Good cap refill. No skin breakdown.
Skin: multiple seb Ks. Few cherry angioma. No suspicious lesions.

Assessment:

  1. Increased fatigue without chest pain
  2. HTN suboptimally controlled on lisinopril 10 mg,
  3. Diabetes with retinopathy, neuropathy, nephropathy on metformin SR 2000 mg bid
  4. Hyperlipidemia on lipitor 10
  5. CHF on lisinopril and lasix 20 mg
  6. Colon ca screening UTD, pneumovax and flu shot UTD, takes baby asa

Plan:

  1. Echo to r/o worsening CHF
  2. Increase lisinopril to 20 mg daily
  3. Zostavax
  4. Vhemistry, cbc, HgA1c, lipid profile
  5. f/u 1 month


Once you have obtained a focused history and exam, you are to make recommendations to the patient, leave the room, and complete an on-line evaluation.

 

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