Joan is a 58 year old white female who is scheduled with you today because she needs refills for her medications. When you look at her record you notice that she has not been in for 14 months. You notice that there are a number of missed appointments on record, but that she has been calling in for refills for her meds; during the last call the office the nurse told her she would need to come in for a visit to obtain any more refills.

Her record indicates that her medications at her last visit included:

 HCTZ 25mg po qd

Simvastatin 20mg qd

Synthroid 25mcg qd

She reports that she takes her blood pressure medication “most of the time” but doesn’t take the simvastatin regularly because of all the “bad” information she reads on-line. She also tells you that she feels good but she wants to get checked out and wants to “get her act together” and start taking care of herself because her brother who is 48 just found out that he has “clogged arteries.” She would like some help with quitting smoking as well.  She tells you that she is “tired” and when walking fatigues easily so she stops.  Has on occasion had “chest pressure” when walking that resolves when she rests.

VS:   BP: 168/94, pulse: 84 and regular, resp: 18

Height: 5’9” Weight: 221lbs

  1. What additional subjective information do you need to obtain?
  2. How will you focus your physical exam? What will you be evaluating the patient for?
  3. What labs and diagnostic tests are indicated and why?
  4. Are any referral indicated right now?

You conduct the visit. The physical exam, with the exception of her blood pressure and weight, are normal.

The diagnostic tests and laboratory test you ordered were normal with the exception of the following:

Fasting Lipids: Total cholesterol: 292, LDL: 196, HDL: 20, triglycerides: 350

Fasting glucose: 182

HgbA1c  8.5

TSH 19

During the follow up visit, you discuss the above labs and their implications.

5.   What will you tell her?

6.  What is Joan’s current 10 years ASCVD risk score? Please include lifetime and optimal risks. What treatment will you recommend based on her risk and why?

Below is link for calculator.!/calculate/estimate/

7.  What is your problem list for Joan?

8.  What is your plan of care including follow-up?

9.  What areas of primary prevention are appropriate for Joan?

10.  What areas of secondary prevention are appropriate for Joan?

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