Case Background
Susan Johnston, a 60-year-old woman with a history of obesity, hypertension, and dyslipidemia, has a family history of heart disease. She reports three months of intermittent burning chest pain and shortness of breath during exertion, which improves with rest. Aside from her hypertension and elevated BMI, her physical exam is largely normal.
History of Present Illness: OLDCARTS Assessment
In preparation for Susan Johnston’s clinic visit, a comprehensive history of the present illness should be taken using the OLDCARTS:
- Onset: When did the chest pain begin? Was it sudden or gradual?
- Location: Where exactly does she feel the pain? Does the pain radiate anywhere else?
- Duration: Has the frequency or intensity changed over the past three months?
- Characteristics: Can she describe the pain in detail?
- Aggravating Factors: Does the pain worsen with specific positions or movements?
- Relieving Factors: Does rest consistently provide relief?
- Treatment: Has she sought treatment for chest pain before?
- Severity: On a scale of 1-10, how severe is the pain?
Physical Examination and Diagnostic Tools
The physical exam should include a thorough cardiovascular, respiratory, and abdominal examination. In addition to the exam findings already provided, an evaluation of jugular venous distention, heart sounds, and carotid bruits should be included (Ahima, 2020). Diagnostic tools should involve an electrocardiogram (ECG) to check for ischemic changes and blood tests to assess cardiac enzymes, lipid profiles, and blood glucose levels. If needed, further investigations, such as stress testing or cardiac imaging, can be ordered.
Plan of Care and Patient Education
The plan of care for Ms. Johnston should focus on managing her cardiovascular risk factors, alleviating her symptoms, and preventing complications. Firstly, lifestyle modification involves encouraging regular physical activity, a balanced diet with reduced fast-food intake, and weight loss to manage obesity. Secondly, pharmacological interventions can be done by prescribing medications to manage her hypertension, dyslipidemia, and potentially anti-anginal medications.
Thirdly, patient education can be facilitated by discussing the importance of monitoring blood pressure, adhering to medications, and recognizing when to seek medical help for worsening symptoms (Ahima, 2020). Fourthly, the follow-up needs to be done by scheduling an appointment to assess her progress, review her symptoms, and adjust medications as needed. Regular check-ups with a primary care physician and potentially a cardiologist referral for further evaluation should be considered.
Reference
Ahima, R. S. (2020). Metabolic syndrome: A comprehensive textbook. Springer.