How to write an Internal Medicine Case Study

How to write an Internal Medicine 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).

Mrs. Susan Johnston is a 60-year-old female presenting to the clinic with complaints of intermittent chest pain that has existed for three months. The patient’s past medical history reveals the aspects of hyperlipidemia, hypertension, diabetes, and a family history of cardiac disease. Despite a prescription of lisinopril, hydrochlorothiazide, and occasional aspirin, Susan states, “I don’t like taking pills.” When asked about the onset of her problems, she explains that it starts when she performs any physical activity like climbing the stairs. She explains that the pain is located in the middle chest of the chest and when experienced it lasts for about two to three minutes. The pain is described as ‘burning’ and sometimes feels like a tingling sensation accompanied by shortness of breath. The pain is aggravated by any form of physical activity and she tries to get rid of it by changing body positions. The severity of the pain is rated 6/10 on the pain intensity 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? 

A complete head-to-toe examination is necessary to obtain additional information that can aid in managing Susan’s health problems. The physical examination should include obtaining vital signs and listening to the heart sounds using a stethoscope. Palpation of the carotid, radial and peripheral arteries is crucial to detect any blood circulation problems. Drawing blood for CBC, TSH, lipid profile, and other basic metabolic profiles is necessary. These tests are crucial in identifying problems like ischemia and coronary artery disease that can cause chest pain (Stepinska et al., 2020). An electrocardiogram is necessary to evaluate the heart rhythms. Susan presents with chest pain and presents with chest pain that indicates problems with the heart and she can greatly benefit from conducting an ECG. An additional test that I would include is a doppler ultrasound to detect any issues with perfusion to the peripherals.

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

The initial plan of care for this patient is to prescribe medication for the chest pain and refer her to a cardiologist for further evaluation. Aspirin 75mg per day can be beneficial for Susan to reduce the risk of myocardial infarction as she awaits further review (Harskamp et al., 2019). Health education for Susan should start with compliance to medication to avoid more complications. The patient should be informed about the signs and symptoms of a worsening condition like severe chest pain radiating to the arms, neck, or jaws, diaphoresis, and dizziness that should prompt seeking immediate medical attention (Stepinska et al., 2020). Lifestyle modification is another aspect that should be stressed during the visit. The patient’s BMI is 35 indicating a risk for conditions like coronary heart disease, and diabetes. Given her positive family history of these conditions, Susan should regulate her diet and seek nutritional counseling for weight management. The follow-up plan should include regular phone calls to ascertain the well-being of the patient and compliance with medication. The patient should also be followed up and evaluated every four to six months after initiation of therapy.

References

Harskamp, R. E., Laeven, S. C., Himmelreich, J. C., Lucassen, W., & van Weert, H. (2019). Chest pain in general practice: A systematic review of prediction rules. BMJ Open, 9(2), e027081. https://doi.org/10.1136/bmjopen-2018-027081

Stepinska, J., Lettino, M., Ahrens, I., Bueno, H., Garcia-Castrillo, L., Khoury, A., … & Huber, K. (2020). Diagnosis and risk stratification of chest pain patients in the emergency department: Focus on acute coronary syndromes. A position paper of the Acute Cardiovascular Care Association. European Heart Journal: Acute Cardiovascular Care, 9(1), 76-89. https://doi.org/10.1177/2048872619885346

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