From the case study, the illness patterns that the patient is engaged in include smoking. Smoking is hazardous to the health of the patient considering she had been admitted in 2005 as a result of chest pains and has a history of other diseases like hypertension which may be reactivated, conversely, smoking may also lead to cancer of the lungs putting the patient in much more harm. Despite of the patient having quit smoking two years ago, the effects of her previous smoking habits are starting to be seen. The beer packs the patient got used to is also a health hazard as alcohol directly leads to liver cirrhosis and with the patient’s history of chest problems it is not healthy. Recently she was diagnosed to be having elevated liver enzymes. These elevated liver enzymes are brought about by the patients living condition of too much drinking of alcohol which adversely affects the liver. She manages her stress well hence she has no psychological problems.
These practices are very dangerous to the patient’s health considering her age, and could worsen her health condition. However, the patient over the years has been practicing health lifestyle. The patient whenever she feels uncomfortable takes medicine and has been consistent with her prescription in good time every day. She does regular exercises which helps her with her chest problems, it also aids keep her muscles fit and has been the reason why she is still able to conduct her activities normally (“Health: Illness and Wellness (2017/090)”. (2017).
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She sees her Primary Care Physician annually which helps keep her health condition in check (Ghosh, 2017). Additionally, she ensures she sees her primary her Cardiologist every 3 months. Maintaining these regular check-ups ensures that no illness gets her by surprise. She also she takes a healthy diet which is a plus for maintaining good health. At 75, she still does her regular chores with ease and this can be attributed to the healthy lifestyle she has been practicing. The patient has positive attitude regarding sickness and health. Furthermore, the patient is prompt and ensure she utilizes the medical facilities in her disposal. The patient engages in secondary prevention of any health condition as she ensures that she attends regular check-ups (Ramaswamy, 2016). Additionally, the patient undergoes annually immunization for flu vaccine, this shows how committed the patient is serious with living a healthy life.
Physical exam
Chest: Breasts: symmetric and atrophic, no masses or discharges, non-tender. Lungs: No dullness to percussion, bibasilar rales, wheezes or rubs Diaphragm moves well with respiration, No rhonchi.
Neck: thyroid not palpable, jugular venous pressure 8cm, No masses.
Nodes: No adenopathy
Heart: PMI at the 6th ICS, 1 cm lateral to MCL. Heaves or thrills not present. Normal rhythm with occasional extra beat. Normal S1, S2 narrowly split; positive S4 gallop. A grade II/VI systolic ejection murmur is heard at the left upper sternal border without radiation. For sharp carotid upstrokes pulses are notable. Pulses: Carotid brachial radial femoral DP PT R 2+ 2+ 2+ 2+ 1+ 0 L 2+ 2+ 2+ 2+ 1+ 0
Spine: mobile, mild kyphosis, nontender, no costovertebral tenderness
Neurological: Awake, fully oriented. Cranial nerves III-XII intact except for decreased hearing. Motor: Strength not tested, patient moves all extremities. Sensory: normal to touch and pin prick. Cerebellar: no dysmetria nor tremor. Reflexes symmetrical 1+ throughout, no Babinski sign.
Formulation
The patient a 75 year old woman with a history of congestive heart failure, and coronary artery disease risk factors of hypertension and post-menopausal state presents with sub-sternal chest pain. The exam showed that she was in sinus tachycardia, without JVD, however, there were pedal edema and bibasilar rales, and this suggested a degree of congestive heart failure. Acute anterolateral myocardial infarction was indicated to be present by changes in EKG, CPK and troponin elevation were showed by the lab reports.
Impression
1. Acute antelorateral myocardioal infarction was complicated by mild left ventricular dysfunction. The patient received thrombolysis therapy.
2. Hypertension
3. Dysuria - 3+ bacteria in urine with pyuria
Plan
1. The patient should continue taking aspirin, heparin, nitrates, beta blockers, nasal oxygen. Follow serial physical exams, labs and EKGs.
2. The murmurs heard on cardiac exam and post MI heart function to be assessed by obtaining echocardiogram. To start early beta blocker therapy if LV ejection fraction is preserved.
3. To continue ACE inhibitor therapy, and ensure blood pressure is monitored.
4. Dysuria and pyuria- probable recurrent cystitis, as she is afebrile and there is no costovertebral tenderness. The Bactrim treatment to be started for presumed uncomplicated urinary tract infection and follow-up on urine culture results.
References
Ghosh, D. (2017). Illness to Wellness: Paradigm Shift in Healthcare Industry. International Journal Of Complementary & Alternative Medicine , 8 (4). http://dx.doi.org/10.15406/ijcam.2017.08.00268
Mental Health: Illness and Wellness (2017/090). (2017). Journal Of Midwifery & Women's Health , 62 (6), 767-768. http://dx.doi.org/10.1111/jmwh.12714
Ramaswamy, B. (2016). Reconceptualising Parkinson's: from illness to wellness using a participatory action research approach. Physiotherapy , 102 , e26. http://dx.doi.org/10.1016/j.physio.2016.10.037
