cardiovascular case

cardiovascular case 150 150 Affordable Capstone Projects Written from Scratch

This week, complete the MedU case titled “SIMPLE Case 2: 60-year-old woman with episodic chest discomfort – Ms. Johnston

 

 

SIMPLE 02. 60-year-old Woman with Chest Pain – Ms. Johnston

INTRODUCTION

CARE DISCUSSION

 

Dr. Lorenzen asks you to see Ms. Johnston.

You are working with Dr. Lorenzen, who asks you to start interviewing Susan Johnston, a patient she knows well who is here to discuss recent symptoms of chest pain.

 

DIFFERENTIAL DIAGNOSIS

Before seeing the patient, Dr. Lorenzen asks you to review the differential diagnosis for chest pain. She reminds you, “There are many causes of chest pain including cardiac, gastrointestinal, pulmonary, musculoskeletal and psychogenic causes.”

1-Question

List below three potential causes of chest pain in each of the categories mentioned

 

 

 

 

 

 

 

CLINICAL REASONING

CHART REVIEW AND HISTORY TAKING

 

.HISTORY

You begin your interview of Ms. Johnston.

You proceed to the patient’s room and review the chart before going into the room.

You learn that Susan Johnston is a 60 year-old woman with a history of hypertension and dyslipidemia. On today’s chart the medical assistant has indicated that Ms. Johnson is having episodes of chest discomfort, and has recorded the vitals:

Vital signs:

  • Temperature:6 Fahrenheit
  • Heart rate:82 beats/minute
  • Respiratory rate:14 breaths/minute
  • Oxygen saturation:94% on room air
  • Blood pressure:138/78 mmHg
  • Weight:220 pounds
  • Height:5’ 6”

 

 

 

Answer Preview

The history of present illness enables us to obtain pertinent data regarding the nature as well as the onset of the symptoms for the condition from which the patient suffers. This information is collected on a wide spectrum of topics including onset, location, duration, characteristics, aggravating, treatment, and severity.

Onset: I would ask the patient when she began experiencing the symptoms. I would also seek to find out if the symptoms began suddenly or gradually developed over time.

Location: I would seek to determine where the pain comes from.

Duration: I would seek to find out if the symptoms are permanent or if they are intermittent.

Characteristics: I would ask the patient to explain in detail what she is experiencing.

Aggravating: I would seek to find out what makes the pain worse and what relieves the pain. It would also be of interest to find out the symptoms that occur simultaneously.

Radiation: I would seek to determine if the pain radiates to other parts of the body.

Treatments: I would seek to establish the sort of steps the patient has taken to help relieve the pain. I would also ask about the outcome of the treatment plans.

Severity: I would seek to now the extent to which the condition affects her life.


 

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