Discuss the history of present illness that you would take on this patient in preparation for the clinic visit.

Comment using your own words but please provide at least one reference for each comment.

Do a half page for discussion #1 and another half page for discussion #2 for a total of one page.

Provide the comment for each discussion separate.

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Discussion #1

1.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).

HPI:

Ms. Susan Johnston is a 60 year old female that presented to the clinic with complaints of intermittent chest pain that has been occurring for the last 3 months on exertion. She has a history of hyperlipidemia, hypertension and a family history of Diabetes and cardiac disease. At the present time she is non-compliant with her current medication regime of lisinopril 20mg, hydrochlorothiazide 25mg and occasional aspirin. 

Ms. Johnston states that her chest pain is in the “middle of her chest” and says her pain level can be 6/10 on the pain scale at its worst. She states that the discomfort occurs when she is “active” climbing stairs and is relieved by rest. Ms. Johnston describes her pain as “burning at times and sometimes tingling” but also stated “it always goes away”. She did state that she has some shortness of breath with the occurrence.

She denies any symptoms of dizziness or passing out. Also denies any radiation of pain to the neck, jaw or arm. She has not been woken by the pain and has no nausea or vomiting during or after pain onset.

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 physical exam to be used on Ms. Johnston includes a full head to toe assessment which showed no abnormalities besides obesity and hypertension.  An EKG was also completed which showed normal sinus rhythm. Labs were drawing including a CBC, TSH, basic metabolic panel, and a fasting lipid panel. CBC allows us to get a foundation of the hemodynamic of her system and check for signs ischemia. By drawing a TSH we can check for possible thyroid dysfunctions that may be contributing to her aliments such as her weight gain. With the lipid panel we can assess the risk to Ms. Johnston for coronary artery disease 

After receiving the Lab results back it was noted that her ASCVD score was at a 7.2% which increases her risk for a cardiac event. A chest xray was completed and Ms. Johnston was sent for stress test and a cardiac Cath procedure where a stent was placed. 

I feel that all the diagnostics and labs performed were appropriate. If we were do add anything possibly dopplers to make sure there are no other signs of lack of perfusion to the peripherals as well.  

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

During the follow up visit we would like to gauge Ms. Johnston’s compliance with her medications. Set up an appointment for 6-12 weeks to redraw the lipid panel to check for compliance (University of Michigan Medicine, 2014).We will discuss possible diet changes and safe physical activities for her to complete in order to better her health and weight.

Discussion #2

Ms. Johnston, a 60-year old patient presented with complaint of non-radiating midline chest pain, onset about 3 moths ago, intermittent in nature and lasting 2-3 minutes after the onset, described as burning with occasional tingling sensations. The patient is not endorsing any aggravating factors, associated with the complaint of this chest pain.The patient didn’t identify any specific relieving factors, stating that the chest pain is self-resolving with worst exacerbation’s pain score of 6/10.

The patient’s initial vital signs are within defined limits, with exception of blood pressure of 138/78, and 136/82 thereafter. Review of medications was performed in order to connect the findings from the physical exam to the medication efficacy. The patient endorses taking lisinopril and hydrochlorothiazide, although is still hypertensive. Family history was obtained, which helps identify the risk factors, as related to the genetic pre-disposition. Paternal family history of heart attack at age 57, which poses a risk factor when looking comprehensively at findings. Social history was obtained and the patient is a non-smoker, which decreases her associated cardiovascular risk. Also, the dietary habits were assessed with the patient shown to be obese with a BMI of 35.5 and denying following healthy diet habits. This finding created a need for associated education and dietary intervention plan. Overall, the physical assessment was within defined limits. I think that additionally, an EKG should be a standard tool of gathering data when related to any patients with complains of chest pain, arrhythmia and/or shortness of breath. In this particular case with Ms.Johnson, she also presents with multiple risk factors that just amplify the need for EKG testing.

This patient should be given a thorough education about the need for lifestyle modifications. The patient needs to follow a heart healthy diet that will help her heart function and also potentially reduce the excess weight. The patient also will need to be instructed that she may benefit from a individually tailored physical activity program and refer her to the resources available. The patient had been started on new medications, so a thorough teaching on medication regiment and medication side effects is warranted. Medication compatibility needs to be assured. The patient will benefit from a referral to cardiology for follow up, so a new evaluation later on can be conducted and see if further need for intervention is warranted. The patient needs to be given education on signs and symptoms of worsening condition, therefore prompting the patient to seek further medical care. It is important to understand that the patient will feel comfortable in received information and navigate it accordingly. Increasing healthcare literacy is paramount. Physicians must promote patient education and engagement through improvement in patients’ health literacy. Health literacy is defined as the capacity to seek, understand, and act on health information. The presumption has been that low health literacy means that physician communication is poorly understood, leading to incomplete self-health management and responsibility and incomplete health care utilization. It is the responsibility of physicians to proactively enable patients to have more accessible interactions and situations that promote health and well-being (Paterick, Patel, Tajik, & Chandrasekaran, 2017).

 

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