1a) What other medications or supplements is the patient taking, if any? 1b) This question would provide important information about potential drug interactions or side effects that could be contributing to the patient’s symptoms. It would also help to identify any underlying health conditions or risk factors. 1c) The answer to this question could reveal potential drug interactions, adverse effects of medications or supplements, or other underlying health conditions that could be contributing to the patient’s symptoms.
1a) Does the patient have a history of tobacco or alcohol use? 1b) This question is important for assessing the patient’s overall health and identifying potential risk factors for certain conditions. Tobacco and alcohol use are known risk factors for many health conditions. 1c) The answer to this question could reveal potential risk factors for certain health conditions, such as cardiovascular disease, respiratory disease, and cancer. It could also provide important information about the patient’s overall health and lifestyle habits.
DOMAIN: PHYSICAL EXAM
2a) Respiratory system: The provider would examine this system to assess the patient’s breathing, lung function, and overall respiratory health. 2b) Abnormal findings could include wheezing, coughing, shortness of breath, decreased lung function, or abnormal lung sounds. For a wellness visit, abnormal findings could include any signs of respiratory distress or abnormalities that would indicate an underlying respiratory condition. 2c) Normal findings would include clear breath sounds, no wheezing or crackles, and normal lung function. 2d) The provider may use a stethoscope to listen to the patient’s breathing, as well as a pulse oximeter to measure oxygen levels in the blood.
3a) Diagnosis: Hypertension (high blood pressure). The pathophysiology of hypertension involves increased pressure in the arteries, which can lead to damage of the blood vessels and organs. This can be caused by a variety of factors, including genetics, lifestyle factors, and underlying health conditions. 3b) Differential diagnosis: Not applicable. 3c) Not applicable.
DOMAIN: LABORATORY & DIAGNOSTIC TESTS
4a) The provider may order a blood pressure measurement, a lipid panel to assess cholesterol levels, and a fasting glucose test to check for diabetes. 4b) Abnormal lab results could include high blood pressure, high cholesterol levels, or elevated blood glucose levels. 4c) Abnormal lab values can indicate an increased risk for cardiovascular disease, diabetes, and other health conditions. 4d) The provider may order an electrocardiogram (ECG) to assess heart function, a renal function panel to assess kidney function, or a urinalysis to check for proteinuria (a sign of kidney damage). 4e) The U.S. Preventive Taskforce recommends regular blood pressure screenings for adults starting at age 18, as well as cholesterol and blood glucose screenings starting at age 35 for those with risk factors or at increased risk for cardiovascular disease.