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Week 1 Case Study

Discuss the history of present illness that you would take on this patient in preparation for the clinic visit. Include questions regarding Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity (OLDCARTS).

Onset: 3 months ago

Location: Middle of the chest

Duration: On exertion but stops with rest

Characteristics: Burning sensation that is localized to the middle of the chest

Aggravating Factors: Exercise

Relieving Factors: Rest

Treatment: Rest

Severity: 6/10 on the VAS pain scale

Describe the physical exam and diagnostic tools to be used for Ms. Johnston. Are there any additional you would have liked to be included that were not?

The examination of Ms. Johnston would begin by having the patient sit in a comfortable position. My first assessment would include an across the room exam. What is her color? IS she pale or normal for her ethnicity? IS there any notable bleeding? How is her airway and breathing? Once these are assessed as within normal limits a head to toe examine would be performed. Assess head, face, and neck for any abnormalities such as discolorations or wounds. Then to the chest and abdomen. Initially checking for and discoloration, bruises, and distension. Then auscultate the chest, heart, and abdomen. Next I would check peripheral pulses as well as capillary refill. Finally, palpate chest and abdomen for any pain or enlargement of the liver. I would then Ms. Johnston is she was having any problems voiding or has noticed anything out of the normal happening to her GU wise. Next I would check ROM in her up extremities and lower extremities as well as her reflexes.

As far as diagnostic tools I would like to order and EKG, chest x-ray, and laboratory tests for Ms. Johnston. The EKG to check for acute coronary syndrome, a chest x-ray to check her lungs, and laboratory tests (CBC, CMP, BNP, Troponin, D-Dimer, Lipid panel, and HA1C). After this I would recommend an echocardiogram and stress test for Ms. Johnston.

 

What plan of care will Ms. Johnston be given at this visit; what is the patient education and follow-up?

The plan for Ms. Johnston after this visit would be to schedule an appointment with cardiology to get the stress test and echocardiogram done. I would send her home with a prescription of nitroglycerin tablets. I would instruct her to take 1 tablet every 5 minutes up to 3 doses to relieve the chest pain if needed. However, if she continues to have chest pain despite the 3 doses of nitro she needs to seek emergency medical treatment immediately. Ms. Johnston will also need to start taking aspirin as well.

As far as education Ms. Johnston will need education as far as medication, lifestyle modifications, and heart education. Lifestyle modifications would include a decrease in food high in fat like friend foods. Also, incorporating daily exercise like walking or swimming. Heart education would include things to reduce her risk of a myocardial infarction, medication compliance, and signs and symptoms that would require immediate medical attention.