Family Medicine · Year 3 · from Family Medicine

Case 1: The Continuity Patient with Multiple Concerns

Patient Demographics

  • Age: 58 years old
  • Sex: Female
  • Occupation: Elementary school teacher

Chief Complaint

"I need to talk about a lot of things today - my knee has been hurting, I'm worried about my blood pressure, and my daughter is going through a divorce."

History of Present Illness

Mrs. Patricia Gonzalez is a 58-year-old woman who has been a patient at this family medicine practice for 15 years. She presents today with multiple concerns. Her right knee has been aching for the past 3 months, worse with climbing stairs at school. She also noticed her blood pressure was 148/92 mmHg at a health fair last week. Additionally, she is visibly tearful when discussing her daughter's recent divorce, stating "I can't sleep worrying about my grandchildren."

She has a history of prediabetes diagnosed 2 years ago, managed with lifestyle modifications. She takes no prescription medications but uses over-the-counter ibuprofen 2-3 times weekly for knee pain.

Past Medical History

  • Prediabetes (HbA1c 6.1% six months ago)
  • Obesity (BMI 31)
  • Hyperlipidemia, not on medication
  • Anxiety, mild, managed without medication

Family History

  • Mother: Type 2 diabetes, hypertension, died of stroke at age 72
  • Father: Coronary artery disease, died of MI at age 68
  • Sister: Type 2 diabetes

Social History

  • Never smoker
  • Occasional alcohol (1-2 glasses of wine on weekends)
  • Married for 35 years
  • Two adult children
  • Active in church community

Physical Examination

  • Vital Signs: BP 152/94 mmHg (repeated: 148/92), HR 78, RR 14, BMI 31
  • General: Well-appearing but appears stressed, tearful at times
  • HEENT: Normal
  • Cardiovascular: Regular rate and rhythm, no murmurs
  • Lungs: Clear bilaterally
  • Musculoskeletal: Right knee with mild crepitus, no effusion, mild medial joint line tenderness, full ROM
  • Neurologic: Normal gait

Clinical Image

Image: A clinician performing a physical examination with a stethoscope, demonstrating the comprehensive approach central to family medicine practice.

Image Source: Wikimedia Commons Attribution: National Cancer Institute, Public Domain URL: https://commons.wikimedia.org/wiki/File:Clinician_uses_a_stethoscope_to_examine_a_patient._(34046256020).jpg

Outpatient Workup

  • Fasting glucose and HbA1c
  • Lipid panel
  • Basic metabolic panel
  • Right knee X-ray (weight-bearing)
  • Home blood pressure monitoring diary
  • PHQ-9 depression screening

Assessment and Diagnosis

  1. Stage 1 hypertension - New diagnosis, requires confirmation with home monitoring
  2. Right knee osteoarthritis - Likely early degenerative disease
  3. Adjustment disorder with anxiety - Related to family stressors
  4. Prediabetes - Ongoing, needs reassessment
  5. Obesity - Contributing to metabolic and musculoskeletal issues

Management Plan

For Hypertension:

  • Initiate home blood pressure monitoring twice daily for 2 weeks
  • Calculate 10-year ASCVD risk (approximately 12% based on current data)
  • Recommend DASH diet counseling
  • Sodium restriction < 2300 mg/day
  • If confirmed on home monitoring, discuss initiating ACE inhibitor given diabetes risk

For Knee Pain:

  • X-ray to confirm osteoarthritis
  • Continue ibuprofen PRN but limit to 2 weeks continuous use
  • Physical therapy referral for quadriceps strengthening
  • Weight loss counseling - target 5% body weight reduction

For Anxiety/Stress:

  • Validate emotional concerns
  • Brief supportive counseling during visit
  • Discuss sleep hygiene strategies
  • Consider referral to behavioral health if symptoms persist
  • Follow up PHQ-9 in 2-4 weeks

For Prediabetes:

  • Repeat HbA1c
  • Reinforce lifestyle interventions (Diabetes Prevention Program referral)
  • Weight loss goal integrated with knee and BP management

Follow-Up

  • Return in 2-3 weeks to review home BP log and lab results
  • Annual comprehensive visit to address all chronic conditions
  • Maintain longitudinal relationship for ongoing support

Teaching Points

  1. Biopsychosocial model: This case illustrates how biological (hypertension, knee pain), psychological (anxiety, stress), and social factors (daughter's divorce, concern for grandchildren) interweave in a single patient encounter.
  1. Continuity of care: Knowing this patient for 15 years provides context that would be impossible in an episodic care model. Her family history, prior health behaviors, and personal values inform today's management.
  1. Comprehensive care: Family medicine addresses multiple problems simultaneously rather than fragmenting care across specialists.
  1. Patient-centered approach: Rather than dismissing her emotional concerns to "focus on medical issues," addressing the psychosocial stressors is essential to overall health and adherence.

All cases for this lecture as Markdown