This Week Complete The Aquifer Case Titled Internal M 050863

This Week Complete The Aquifer Case Titled Internal Medicine 02 60

This week, complete the Aquifer case titled “Internal Medicine 02: 60-year-old woman with chest pain.” Use information from the case study to answer the following questions:

1. Discuss the history of present illness (HPI) you would take from this patient in preparation for the clinical visit. Include questions related to Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, and Severity (OLDCARTS).

2. Describe the physical examination and diagnostic tools to be used for Ms. Johnston. Mention any additional assessments you would have included but did not.

3. Outline the plan of care for Ms. Johnston during this visit, including patient education and follow-up steps.

Paper For Above instruction

In evaluating Ms. Susan Johnston, a comprehensive and systematic approach is essential to accurately diagnose her condition and formulate an effective plan of care. Her presentation of chest pain, with a history spanning three months and characteristics suggestive of anginal symptoms, warrants thorough history-taking, physical examination, diagnostic evaluation, and patient education.

Start with an extensive history of present illness (HPI). It is vital to gather detailed information about the onset of her chest pain—whether it began gradually or suddenly—and the circumstances under which it occurs. Given her description, questions should explore whether the pain is strictly exertional, occurs at rest, or both, and if the duration of each episode is consistent. Quantifying the pain's severity on a 10-point scale provides insight into her discomfort level. Further, the character of the pain—burning and tingling sensations—raises considerations about its nature. It is crucial to clarify whether these sensations are typical of ischemic pain or suggest other etiologies like gastroesophageal reflux disease (GERD). Understanding aggravating factors such as physical exertion and calming influences—like drinking cold water—helps delineate potential triggers. The absence of radiation to her jaw, arm, or neck, and the fact that episodes do not awaken her, offer additional clues. She reports associated symptoms like shortness of breath but denies nausea, sweating, or palpitations, which could influence differential diagnoses.

Physical examination should encompass vital signs—heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation—to establish baseline parameters and identify abnormalities. Auscultation of the heart and lungs can reveal murmurs, gallops, or crackles indicative of heart failure or other pathology. Palpation of carotid, radial, and dorsalis pedis arteries assesses peripheral perfusion and presence of vascular disease. A quick inspection of the head, eyes, ears, nose, and throat (HEENT) can exclude other sources of chest discomfort. Examination of the abdomen should evaluate for any abdominal pathology that could simulate chest pain. Additionally, inspecting extremities for edema and palpating for pulses provide insight into peripheral circulation quality. An electrocardiogram (ECG) is essential for detecting ischemic changes or arrhythmias. Further diagnostic tools such as stress testing, echocardiography, or coronary angiography might be necessary based on initial findings.

It is important to recognize additional assessments that could be valuable but were not included. For instance, laboratory testing such as cardiac enzymes (troponins), lipid profile, and blood glucose levels can assist in risk stratification. A chest X-ray can rule out pulmonary causes. Additionally, an exercise stress test or nuclear imaging could provide functional information about her myocardial perfusion and ischemia risk.

Regarding her plan of care, initial management should focus on risk modification. Given her history of hypertension, hyperlipidemia, obesity (BMI of 35), sedentary lifestyle, and family history of premature coronary artery disease (father's heart attack at age 57), she requires aggressive lifestyle interventions. Counseling about diet, physical activity, smoking cessation (if applicable), and weight management is crucial. Pharmacologically, initiating antiplatelet therapy with low-dose aspirin (75-325 mg daily) is justified for her at-risk profile, aligning with guidelines to prevent myocardial infarction and ischemic stroke. Statin therapy should be considered to control hyperlipidemia, alongside antihypertensives to achieve target blood pressure levels.

Patient education is paramount. Ms. Johnston should learn to recognize warning signs of a myocardial infarction, including chest pressure radiating to the jaw, arms, or neck, accompanied by diaphoresis, nausea, dyspnea, dizziness, or palpitations. Emphasize the importance of activating emergency services immediately if these symptoms occur. Clear guidance on medication adherence, monitoring blood pressure and lipid levels, and maintaining a healthy lifestyle should be provided. Scheduled follow-up with her primary care provider and referral to a cardiologist for further evaluation—including possible stress testing or angiography—is advised to confirm diagnosis and tailor ongoing management.

Overall, a multifaceted approach integrating history, physical examination, diagnostics, lifestyle counseling, medication management, and patient education aims to reduce her risk of a cardiac event and improve her health outcomes.

References

• Lowry, P. (2017). Chest pain and coronary artery disease. In T. M. Buttaro, J. Trybulski, P. Polgar-Bailey, & J. Sandberg-Cook (Eds.), Primary care: A collaborative practice (pp. 550-560). Elsevier.
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• Fletcher, G. F., et al. (2014). Updated guidelines on physical activity and sedentary behavior from the American Heart Association. Circulation, 131(22), e285-e286.
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• Thygesen, K., et al. (2018). Fourth universal definition of myocardial infarction. Journal of the American College of Cardiology, 72(18), 2231–2264.
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• Fihn, S. D., et al. (2012). American College of Cardiology/American Heart Association American guideline for the management of patients with stable ischemic heart disease. Circulation, 126(25), e354–e425.