6001-W1-D12
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Fazaia Degree College, M.R.F, Kamra, Attock *
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Course
6001
Subject
Medicine
Date
Nov 24, 2024
Type
docx
Pages
2
Uploaded by maryamberlas
Discuss history of present illness that you would take on this patient in preparation for the clinic visit.
Onset: The patient states that the chest pain started approximately 3 months ago
Location: The pain is located in the middle of her chest
Duration: The patient did not mention a specific amount of time that the pain lasts.
Characteristics: Burning with a tingling sensation
Aggravating Factors: It is aggravated with any sort of activity.
Relieving Factors: The pain is alleviated with rest.
Treatment: The patient did not mention any specific treatments that she does for the pain.
Severity: Patient states that the pain is 6/10.
Describe physical exam and diagnostic tools to be used for Ms. Johnson. Are there are any additional you
would like to have included that were not?
The patient had an ECG done in the office that showed NSR with assorted flat T and inverted T waves.
These abnormalities are considered non-specific to the patient and may be considered normal for the
patient. The patient then had a stress test that showed 2mm downslopping ST segments that resolved
after the patient had a chance to stop and rest. Because of the stress test results, the patient was sent to
the hospital where a coronary angiography was performed that revealed the left anterior descending
artery was occluded. There was no other testing that I would like to have performed, the testing
performed on the patient was appropriate.
What plan of care will Ms. Johnson be given at this visit; what is the patient education and followup?
Once home, the patient should be educated on monitoring the insertion site for signs and symptoms of
infection or bleeding such as odd pain, swelling, discoloration, fever, or redness. The insertion site should
be kept clean and dry so during this time swimming or bathtub use is discouraged (John Hopkins
Medicine, 2023). Strenuous activities should be avoided and the patient will be instructed on when she
can return to work and resume normal activities (John Hopkins Medicine, 2023). The patient should be
educated on the importance of a balanced diet with lean proteins, fresh produce, decreased sugary
beverage intake, and decreasing the amount of fast food consumed. The patient should also be
instructed on a heart healthy diet that includes lowering sodium intake (American Heart Association
[AHA], n.d.). The patient should be educated on the importance of keeping her blood pressure within a
normal range through dietary intake, exercise, and taking prescribed medications (American Heart
Association, 2017). The patient should monitor her blood pressure at home and know understand the
numbers as well as when to contact her physician or go to the ER. Finally, Ms. Johnson should keep up
with all appointments scheduled by the provider to ensure proper follow up care.
References American Heart Association. (n.d.). Managing blood pressure with a heart healthy diet.
American Heart Association. (2017, November 30). Five simple steps to control your blood pressure.
heart.org. Retrieved April 12, 2023, from
https://www.heart.org/en/health-topics/high-
bloodpressure/the-facts-about-high-blood-pressure/five-simple-steps-to-control-your-blood-pressure
John Hopkins Medicine. (2023). Angioplasty and stent placement for the heart. hopkinsmedicine.org.
Retrieved October 26, 2023, from
https://www.hopkinsmedicine.org/health/treatment-tests-and-
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