# Clinical Cases: Principles of 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 ![Clinical examination with stethoscope](case_01_image.jpg) *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. 2. **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. 3. **Comprehensive care:** Family medicine addresses multiple problems simultaneously rather than fragmenting care across specialists. 4. **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. --- ## Case 2: The Three-Generation Family Visit ### Patient Demographics - **Age:** 4 years old - **Sex:** Male - **Accompanied by:** Mother (32 years old) and Grandmother (58 years old) ### Chief Complaint Child: "My ear hurts" Mother: "I also wanted to ask about my migraines" Grandmother: "Since I'm here, can you check my blood sugar?" ### History of Present Illness **Child (Marcus):** 4-year-old boy with 2 days of right ear pain, preceded by runny nose for 5 days. Low-grade fever (100.4F) yesterday. Tugging at right ear. Appetite slightly decreased. No vomiting or diarrhea. **Mother (Jasmine):** Has been experiencing migraine headaches 3-4 times monthly for the past 6 months. Throbbing, unilateral, associated with nausea and photophobia. Using OTC acetaminophen and ibuprofen with partial relief. Headaches are affecting her work as a nursing assistant. **Grandmother (Denise):** Known diabetic, wondering if her blood sugar is controlled. Last HbA1c was 7.8% three months ago. Taking metformin 1000mg twice daily. ### Physical Examination **Marcus (Child):** - **Vital Signs:** Temp 99.8F, HR 100, RR 20 - **General:** Active but irritable 4-year-old - **HEENT:** Right TM bulging, erythematous, decreased mobility; Left TM normal - **Neck:** Small anterior cervical lymphadenopathy - **Lungs:** Clear **Jasmine (Mother):** - **Vital Signs:** BP 118/76, HR 72 - **Neuro:** No focal deficits, no papilledema **Denise (Grandmother):** - **Vital Signs:** BP 138/84, HR 78, BMI 34 - **General:** Well-appearing - **Feet:** No ulcers, intact sensation ### Assessment and Plan **Marcus - Acute Otitis Media:** - High-dose amoxicillin 90 mg/kg/day divided BID for 10 days - Acetaminophen PRN for pain/fever - Return if worsening or no improvement in 48-72 hours - Follow up in 2-3 weeks to confirm resolution **Jasmine - Episodic Migraine:** - Meets migraine diagnostic criteria - Trial of sumatriptan 50mg at headache onset - Headache diary to identify triggers - Discuss preventive therapy if frequency continues - Return in 4-6 weeks to assess response **Denise - Type 2 Diabetes Management:** - Order HbA1c today - Schedule dedicated diabetes visit in 2 weeks for comprehensive management - Continue metformin - Review diet and exercise at next visit ### Teaching Points 1. **Family-centered care:** Caring for multiple generations of the same family is a hallmark of family medicine. This provides insight into family dynamics, genetic predispositions, and social support systems. 2. **Efficiency and access:** Addressing multiple family members' needs in a single visit improves access and convenience while maintaining appropriate care for each individual. 3. **Genogram utility:** Understanding family relationships helps identify patterns (grandmother's diabetes informs granddaughter's risk counseling in the future). --- ## Case 3: Navigating the Healthcare System ### Patient Demographics - **Age:** 67 years old - **Sex:** Male - **Occupation:** Retired factory worker ### Chief Complaint "I'm confused about all my medications and doctors. I just got out of the hospital and don't know what I'm supposed to do." ### History of Present Illness Mr. Harold Washington is a 67-year-old man who was hospitalized 5 days ago for community-acquired pneumonia. He was discharged yesterday with multiple medication changes. He brings a bag with 12 medication bottles and discharge papers from the hospital. His wife is with him and appears overwhelmed. During hospitalization, his home blood pressure medication (amlodipine) was stopped and replaced with lisinopril. His chronic pain medication was changed from tramadol to acetaminophen. He was started on levofloxacin to complete a 7-day antibiotic course. He was also told to follow up with his cardiologist "soon" but doesn't know how to arrange this. ### Medication Reconciliation **Pre-hospitalization medications:** - Amlodipine 10mg daily - Metformin 1000mg twice daily - Atorvastatin 40mg daily - Tramadol 50mg twice daily - Aspirin 81mg daily **Discharge medications:** - Lisinopril 10mg daily (NEW) - Metformin 1000mg twice daily - Atorvastatin 40mg daily - Acetaminophen 650mg every 6 hours PRN (NEW) - Aspirin 81mg daily - Levofloxacin 750mg daily x 3 more days (NEW) - Guaifenesin as needed (NEW) **Discrepancy identified:** Patient still has amlodipine at home and was taking it along with lisinopril, not realizing the switch. ### Assessment 1. **Post-hospitalization transition** - High-risk period requiring careful coordination 2. **Medication discrepancy** - Taking both amlodipine and lisinopril (duplicate BP therapy) 3. **Community-acquired pneumonia** - Recovering, completing antibiotics 4. **Care coordination needed** - Multiple specialists, unclear follow-up ### Management Plan **Medication Reconciliation:** - Discontinue amlodipine (replaced by lisinopril per hospital team) - Confirm all other medication changes with patient and wife - Create updated medication list for patient to carry **Care Coordination:** - Call cardiology office to schedule follow-up appointment - Ensure pneumonia follow-up chest X-ray in 6 weeks - Schedule diabetes follow-up in 2-4 weeks for HbA1c **Patient Education:** - Reviewed each medication's purpose with patient and wife - Provided written medication schedule - Discussed warning signs requiring immediate attention **Communication:** - Send summary to cardiologist and hospitalist - Document all care coordination activities ### Teaching Points 1. **Care coordination role:** The family physician serves as the "quarterback" coordinating care across settings and specialists. 2. **Transition of care:** The post-hospitalization period is high-risk for adverse events, medication errors, and readmission. A timely PCP follow-up within 7-14 days is essential. 3. **Health literacy:** Patients often don't understand medication changes. Taking time to review the medication list prevents errors. 4. **Patient-centered medical home:** This case demonstrates PCMH functions including care coordination, population health (identifying high-risk transitions), and comprehensive care.