Fluent Essays

Reply to my peers please see attachments 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 (OLD CARTS). In order to determine the cause of a patients symptoms, it is significant to analyze their history of present illness (HPI). HPI helps the provider to understand the patients condition since it gives a chronological description of a patients condition from the onset of the symptoms to the present manifestations. Furthermore, it helps providers evaluate a patients condition and make a diagnosis since clinicians make a diagnosis based on a patients medical history alone. Therefore, to evaluate Ms. Johnstons history of present illness, it is significant to use the OLD CARTS (onset, location, duration, characteristics, aggravating factors, relieving factors, treatment, severity (Ingram, 2017). This is a significant guideline to help providers better understand a patients condition in order to make the most appropriate diagnosis. In addition, OLD CART enables providers to frame their questions to allow the patient to give answers that enable the clinician to understand the illness from the patients viewpoint. In this case, since Ms. Johnston is primarily complaining of chest pain, I would ask her the following questions to enable me to understand her condition better and make the correct diagnosis. · When did the pain start?  · How do you feel now? · Where exactly do you feel the pain?  · Do you sometimes feel it in different areas, or is it just the same spot since it started? · Is the pain continuous, or it comes and goes depending on activity? · Would you mind describing how it occurs? · What causes the pain to worsen?  · What lessens the severity of the pain?  · Are you experiencing the pain for the first time, or have you experienced it before? · What is your current treatment for chest pain? · Is the pain mild or severe? · How would you rate the intensity of the pain on a scale of 1-10? 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? A patient can present chest pain due to several factors like cardiovascular conditions and gastrointestinal diseases. Chest pain can also occur due to psychogenic causes, dermatologic/musculoskeletal diseases, and pulmonary conditions. It is significant to conduct a physical examination to provide a specific etiology to determine which factor is responsible for Ms. Johnstons chest pain. Physical examination is based on physically evaluating the patient by observing vital signs like pallor and physical appearance; patients with chest pain always appear uncomfortable and anxious. It is also crucial to evaluate the patient from head to toe to identify any vital signs in the cardiopulmonary system significant to develop a diagnosis. Conducting auscultation and palpitations is also an essential physical activity to determine if the patients pain is due to cardiovascular diseases or other factors. Auscultation and palpitations would enable evaluate the lungs by assessing abnormal sounds like wheezing and determine whether the patients heart rhythm is regular (Thibodeau, 2017). The additional diagnostic tools I would use to rule out other factors and develop the correct diagnosis are; chest X-ray to examine the patients blood vessels, lungs, and heart. Other diagnostic test include; electrocardiogram, echocardiogram, and blood test. What plan of care will Ms. Johnston be given at this visit; what is the patient education and follow-up? The most appropriate plan of care for Ms. Johnston would be to prescribe aspirin and beta blocker to control the pain (Kilian et al., 2020). Patient education, especially include pharmacological adherence to the new therapeutic plan. Promoting dietary modification to reduce weight would also be critical to help the patient maintain a healthy living to reduce the risk of chest pain. It is also significant to educate the patient about exercise regimen to increase HDL Levels.  A follow-up plan would include Hypertension, Hypercholesterolemia and Obesity control , and periodic heart Ultrasound  to evaluate how the patient responds to her new care plan. References Ingram, S. (2017). Taking a comprehensive health history: Learning through practice and reflection. British Journal of Nursing, 26(18), 1033-1037.  https://doi.org/10.12968/bjon.2017.26.18.1033 Kilian, A., Upton, L. A., & Sheagren, J. N. (2020). Reorganizing the History of Present Illness to Improve Verbal Case Presenting and Clinical Diagnostic Reasoning Skills of Medical Students: The All-Inclusive History of Present Illness. Journal of Medical Education and Curricular Development, 7, 238212052092899. https://doi.org/10.1177/2382120520928996   Thibodeau, D. T. (2017). Evaluation of Chest Pain in the Primary Care Setting. Physician Assistant Clinics, 2(4), 571–588. https://doi.org/10.1016/j.cpha.2017.06.011 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.