South University 60 Year-Old Woman with Chest Pain Case Discussion

This week, complete the Aquifer case titledInternal Medicine 02: 60-year-old woman with chest pain

Apply information from the Aquifer Case Study to answer the following discussion questions:

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

Expert Solution Preview

Introduction:
In this case study, we will be discussing the medical history, physical examination and diagnostic tools used on a 60 year old woman who is experiencing chest pain. We will then develop a plan of care for the patient, discuss her education and follow-up.

1. To prepare for the clinic visit, we would take a thorough history of present illness, using the OLDCARTS mnemonic. This mnemonic is used to assess onset, location, duration, characteristics, aggravating factors, relieving factors, treatment and severity of the patient’s symptoms. In Ms. Johnston’s case, we would ask questions such as: when did the chest pain start, where is the pain located, how long does it last, what is the pain like, what makes the pain worse, what makes it better, has the patient taken any medication for the pain and how severe is the pain.

2. The physical exam and diagnostic tools used for Ms. Johnston would depend on her presenting symptoms and history. A standard physical examination would include auscultation of the heart and lungs, assessment of vital signs, and palpation of the chest and abdomen. An electrocardiogram (ECG) would be done to look for any cardiac abnormalities. Blood tests would also be done to check for any enzyme releases indicating cardiac muscle damage. Additional tests may include a chest X-ray and CT scan of the chest for suspected cardiac or pulmonary disease.

3. The plan of care for Ms. Johnston would depend on the underlying cause of her chest pain. If the chest pain is due to cardiac pathology, she will be referred to cardiology for further evaluation. If the pain is due to pulmonary causes such as a pneumonia or pulmonary embolism, she may be referred to pulmonary medicine. Pain management will be initiated as necessary. Patient education regarding medication compliance, rest, and hydration will be provided. Follow-up appointments with the appropriate specialist will also be scheduled.

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