12 Primary Care Patient Scenarios with Diagnosis and Treatment Plans
1. Acute Upper Respiratory Tract Infection
Diagnosis: Acute viral upper respiratory tract infection (common cold)
Treatment Plan:
- For adults, provide symptomatic treatment with over-the-counter analgesics, zinc, nasal decongestants (with or without antihistamines), and ipratropium for cough 1, 2
- Avoid antibiotics as they provide no benefit for viral URTIs and increase adverse effects in adults 3
- For children older than 1 year, consider honey for cough, nasal saline irrigation, and topical application of ointment containing camphor, menthol, and eucalyptus oils 2
- Avoid over-the-counter cold medications in children younger than 4 years 2
- Counsel on good hand hygiene to prevent transmission 2
- Inform patient about the self-limited nature of the condition (typically 7-10 days) 1
2. Hypertension
Diagnosis: Essential hypertension
Treatment Plan:
- Begin with lifestyle modifications including weight reduction, DASH diet, sodium restriction, physical activity, and moderation of alcohol consumption 4
- Initiate pharmacologic therapy based on blood pressure levels and cardiovascular risk factors 4
- For stage 1 hypertension (BP 130-139/80-89 mmHg) with high cardiovascular risk, start with a thiazide diuretic, ACE inhibitor, ARB, or calcium channel blocker 4
- For stage 2 hypertension (BP ≥140/90 mmHg), begin with two antihypertensive medications of different classes 4
- Schedule regular follow-up visits to monitor blood pressure control and medication adherence 4
- Screen for and manage other cardiovascular risk factors (smoking, obesity, sedentary lifestyle) 4
- Monitor for development of target organ damage and comorbid conditions 5
3. Type 2 Diabetes Mellitus
Diagnosis: Type 2 diabetes mellitus
Treatment Plan:
- Start metformin as first-line pharmacologic therapy unless contraindicated 4
- Provide comprehensive diabetes self-management education and support 4
- Recommend lifestyle modifications including medical nutrition therapy, physical activity, and weight management 4
- Set individualized glycemic targets (typically HbA1c <7% for most adults) 4
- Screen for and manage diabetes-related complications (retinopathy, nephropathy, neuropathy) 4
- Add second-line agents based on patient-specific factors and comorbidities if glycemic targets not met with metformin 4
- Address cardiovascular risk factors aggressively, as diabetes is associated with increased cardiovascular morbidity and mortality 5
- Schedule regular follow-up visits for monitoring of glycemic control and complications 4
4. Depression
Diagnosis: Major depressive disorder
Treatment Plan:
- Initiate treatment with either psychotherapy (cognitive-behavioral therapy) or pharmacotherapy (selective serotonin reuptake inhibitor) 4
- For moderate to severe depression, consider combination of psychotherapy and pharmacotherapy 4
- Start antidepressant at low dose and titrate gradually to minimize side effects 4
- Educate patient about expected timeframe for improvement (2-4 weeks) and importance of medication adherence 4
- Schedule follow-up within 1-2 weeks of starting medication to assess for adverse effects and suicidal ideation 4
- Continue treatment for at least 6-12 months after remission to prevent relapse 4
- Screen for and address comorbid conditions, particularly cardiovascular disease, which has a bidirectional relationship with depression 4
- Consider psychiatric referral for treatment-resistant depression or complex presentations 4
5. Asthma
Diagnosis: Asthma
Treatment Plan:
- Implement a stepwise approach to treatment based on asthma severity and control 4
- For mild intermittent asthma, prescribe short-acting beta-agonist (SABA) as needed 4
- For persistent asthma, initiate low-dose inhaled corticosteroid (ICS) as controller medication 4
- Provide patient education on proper inhaler technique and medication adherence 4
- Develop a written asthma action plan for managing exacerbations 4
- Identify and address environmental triggers and comorbid conditions 4
- Schedule regular follow-up visits to assess asthma control and adjust therapy as needed 4
- Consider step-up therapy (increasing ICS dose, adding long-acting beta-agonist) for uncontrolled symptoms 4
- Monitor for medication side effects and complications 4
6. Hyperlipidemia
Diagnosis: Hyperlipidemia
Treatment Plan:
- Calculate 10-year atherosclerotic cardiovascular disease (ASCVD) risk to guide treatment decisions 4, 5
- Recommend therapeutic lifestyle changes including heart-healthy diet, regular physical activity, and smoking cessation 4
- For patients with established ASCVD or very high risk, initiate high-intensity statin therapy 5
- For primary prevention, select statin intensity based on calculated ASCVD risk 4
- Monitor lipid levels 4-12 weeks after initiating therapy and then every 3-12 months as needed 4
- Assess for statin-associated side effects, particularly muscle symptoms 4
- Consider non-statin therapies (ezetimibe, PCSK9 inhibitors) for high-risk patients not achieving LDL-C goals with maximally tolerated statin therapy 5
- Address other cardiovascular risk factors concurrently, as hyperlipidemia is the second most prevalent comorbidity across cardiovascular conditions 5
7. Urinary Tract Infection
Diagnosis: Acute uncomplicated urinary tract infection
Treatment Plan:
- For uncomplicated cystitis in women, prescribe first-line antibiotics: nitrofurantoin, trimethoprim-sulfamethoxazole (if local resistance <20%), or fosfomycin 4
- Typical treatment duration is 3-5 days for nitrofurantoin, 3 days for trimethoprim-sulfamethoxazole, and single dose for fosfomycin 4
- Recommend increased fluid intake and urinary analgesics (phenazopyridine) for symptom relief 4
- For men or complicated UTIs, consider longer treatment duration (7-14 days) and broader-spectrum antibiotics 4
- Obtain urine culture before treatment in men, pregnant women, and patients with complicated UTIs 4
- Evaluate for structural or functional abnormalities in patients with recurrent UTIs 4
- Provide preventive strategies for women with recurrent UTIs (postcoital voiding, cranberry products) 4
- Follow up to ensure symptom resolution and address any persistent symptoms 4
8. Chronic Obstructive Pulmonary Disease (COPD)
Diagnosis: Chronic Obstructive Pulmonary Disease
Treatment Plan:
- Smoking cessation is the most important intervention to slow disease progression 6
- Prescribe bronchodilators as first-line therapy for symptomatic patients 6
- For patients with persistent symptoms and FEV1 <60% predicted, consider combination therapy with long-acting beta-agonist (LABA) and long-acting muscarinic antagonist (LAMA) such as tiotropium 7
- Provide pneumococcal and annual influenza vaccinations 6
- Refer for pulmonary rehabilitation for patients with functional limitations 6
- For frequent exacerbations, consider adding inhaled corticosteroids to bronchodilator therapy 6
- Prescribe oxygen therapy for patients with severe resting hypoxemia (PaO2 ≤55 mmHg or SaO2 ≤88%) 6
- Consider noninvasive positive pressure ventilation for patients with acute respiratory failure with pH <7.35 6
- Develop an action plan for early recognition and treatment of exacerbations 6
9. Gastroesophageal Reflux Disease (GERD)
Diagnosis: Gastroesophageal Reflux Disease
Treatment Plan:
- Begin with lifestyle modifications: weight loss, head of bed elevation, avoiding meals 2-3 hours before bedtime, and avoiding trigger foods 4
- Initiate empiric trial with proton pump inhibitor (PPI) such as omeprazole for 4-8 weeks 8
- For erosive esophagitis, continue PPI for 4-8 weeks, with potential extension for another 4 weeks if symptoms persist 8
- After symptom resolution, attempt step-down therapy to the lowest effective PPI dose or on-demand therapy 4
- Consider H2-receptor antagonists for breakthrough symptoms or as maintenance therapy after PPI discontinuation 4
- Evaluate for alarm symptoms (dysphagia, weight loss, anemia) that warrant endoscopic evaluation 4
- For refractory symptoms, consider referral to gastroenterology for further evaluation 4
- Monitor for potential adverse effects of long-term PPI use (vitamin B12 deficiency, hypomagnesemia, C. difficile infection) 4
10. Osteoarthritis
Diagnosis: Osteoarthritis
Treatment Plan:
- Begin with non-pharmacologic approaches: exercise, weight loss, physical therapy, and assistive devices 4
- Start pharmacologic therapy with acetaminophen for mild to moderate pain 4
- For inadequate response, consider topical NSAIDs (for knee or hand OA) or oral NSAIDs at the lowest effective dose 4
- Use oral NSAIDs with caution in elderly patients and those with cardiovascular, renal, or gastrointestinal risk factors 4
- Consider intra-articular corticosteroid injections for acute pain flares 4
- For patients with inadequate response to conservative measures, consider referral for orthopedic evaluation 4
- Provide education about joint protection techniques and self-management strategies 4
- Assess pain control, functional status, and medication side effects at follow-up visits 4
11. Anemia
Diagnosis: Iron deficiency anemia
Treatment Plan:
- Initiate oral iron supplementation (ferrous sulfate, ferrous gluconate, or ferrous fumarate) 4, 5
- Recommend taking iron on an empty stomach with vitamin C to enhance absorption 4
- Educate patient about common side effects (constipation, nausea, black stools) and management strategies 4
- Investigate underlying cause of iron deficiency (menorrhagia, gastrointestinal blood loss, malabsorption) 4
- For premenopausal women with heavy menstrual bleeding, consider hormonal management 4
- For patients >50 years or with evidence of GI blood loss, refer for endoscopic evaluation 4
- Monitor hemoglobin and iron studies after 4-8 weeks of therapy 4
- Continue iron supplementation for 3-6 months after normalization of hemoglobin to replenish iron stores 4
- Consider parenteral iron for patients with intolerance to oral iron or inadequate response 5
12. Attention-Deficit/Hyperactivity Disorder (ADHD)
Diagnosis: Attention-Deficit/Hyperactivity Disorder
Treatment Plan:
- For children ≥6 years and adolescents, initiate FDA-approved medication (stimulant preferred) along with behavioral therapy 6
- Start with low dose of medication and titrate based on response and side effects 6
- Monitor height, weight, blood pressure, heart rate, and potential side effects at follow-up visits 6
- Implement school accommodations and behavioral interventions 6
- Assess for common comorbidities (learning disabilities, anxiety, mood disorders, oppositional defiant disorder) 6
- Provide parent training in behavior management for children with ADHD 6
- Schedule regular follow-up visits to assess symptom control and adjust treatment as needed 6
- Develop a plan for medication holidays if appropriate 6
- Consider the chronic care model and medical home approach for ongoing management 6