Examination and Health History

Initials of Client/Patient: M.W.
Gender: female
45 years old
Client/Occupation: Patient's Teacher
Review of Systems/History of Health
System of the Nervous System: She has no problems with incoordination, weakness, or numbness.
Head and Neck: She has no injuries to her neck or head, and her neck moves effortlessly without resistance.
Conjunctiva and sclera are expected in the eyes. Pupils are evenly distributed.
External auditory canals and tympanic membranes are found in the ears. ordinary
Normal nasal mucosa in the nose, mouth, and throat. The oral pharynx without exudate is normal. Her gums and tongue are normal.
Her skin, hair, and nails are all in good condition, with an average temperature, appearance, and texture.
The Vascular and Lymphatic Systems of the Periphery: There is no lymphadenopathy.
No carotid artery, no RRR, no m/r/g, and no JVD.
Thorax and Lungs: No crackles, no use of accessory muscles, easy to see. Musculoskeletal System: no swollen joints, normal range of motion, 5/5 strength
Gastrointestinal System: No constipation
Genitourinary System: No pain on urination
Physical Examination

Neurological System:
All her twelve cranial nerves are normal. Examination of upper and lower motor and sensory extremities is normal
Head and Neck:
Her head and neck exhibit normal movement. Adenopathy in the supraclavicular or cervical areas is normal
Eyes: The examination shows normal vessels without hemorrhage.
Ears: Ringing ears
Nose, Mouth, and Throat:
Frequent nosebleeds, dry mouth, and hoarseness
Skin, Hair, and Nails: Her hair, skin, and nails are normal
Peripheral Vascular and Lymphatic System: She has a normal venous filling. Peripheral edema
Cardiovascular System; she has short of breath when walking, and chest pain on exertion.
Thorax and Lungs: She normal thorax and lungs
Musculoskeletal System: No joint tenderness and no changes in strengths.
Gastrointestinal System: She complained of nausea, dysphagia, vomiting. She experience change in stool color, pattern or consistency.
FHP Assessment
Cognitive-Perceptual Pattern:
She has no sensory deficits however functions are affected due to age. She communicates well, and her expression is logical. Miriam is a teacher by profession, and she graduated with a bachelor degree. She reported that she feels pain radiating on her abdomen often associated with her periods.

Nutritional-Metabolic Pattern:
Miriam is well nourished, and her daily food intake is within the recommended levels. Her hypertension condition does not affect Miriam’s nutrition-metabolic pattern.
Sexuality-Reproductive Pattern: Miriam has been married for thirty years, and she lives with her husband. She does not have any history of sexually transmitted diseases or reproductive system dysfunction. She is satisfied with her plans regarding children.
The pattern of Elimination:
Miriam has normal bowel habits; she experiences at least two bowel excretions every day with no tarry, blood or mucus in stool. She has no infections in the urinary system, digestive system or skin.
The pattern of Activity and Exercise:
The patient mainly stays within the house, and occasionally she spends some time outside weeding her garden. Usually, she takes a walk when visiting a store to buy products or when she visits her neighbors. She does not experience any respiratory complication associated with these activities.
The pattern of Sleep and Rest:
She can sleep for six to eight hours per night. Her earliest time in going to sleep is at 9:00 PM and her latest time to wake up is 6:00 AM. As one can observe, Miriam looks physically relaxed and rested.
The pattern of Self-Perception and Self-Concept:
Wearing glasses for reading is her only unusual appearance. Miriam is comfortable with her appearance. She feels hopeful to be relieved and treated.


Summarize Your Findings

Situation:
Miriam Walker was admitted to California Pacific Medical Center (CPMC) on first July 2006 after complaining of chest pains that had lasted for five days.

Background:
Miriam Walker, a 45-year-old woman, had never experienced chest pains in her life, and therefore this marked her first admission to the facility. She reported that she was in good health until five days before her admission where she began to experience the onset of chest pains that lasted for several minutes. In the past, Miriam has no records of any heart problems, claudication, chest pains and diabetes; however, she was diagnosed with hypertension (HTN) three years ago. On further examination, Miriam had a family history of premature CAD, and she was not under any hormone replacement therapy. Besides, she was not aware of her cholesterol level.

Assessment:
The description of the patient of aching, dull and exertion brought about by substernal chest pain reveals that the pain originates from Ischemic cardiac. Since the patient was diagnosed with early surgical menopause and hypertension, it is more than likely that she will develop coronary artery disease because of these related risk factors. Therefore, these multiple risk factors alongside the patient’s presentation suggest that angina pectoris is the most appropriate diagnosis. Besides, the occurrence of pain in an increasing manner during rest further highlights the presentation of unstable angina and thus adequate hospitalization with proper medication is required.

Recommendation:

1. The patient should be treated with platelet inhibitors to lower the risk of developing myocardial infarction; to lower the occurrence of pain symptoms and risk of occlusion the patient should be treated with nitrates medication. In case she fails to respond immediately to nitrates, the analgesic such as morphine should be administered.
2. The patient should be monitored carefully to access any prolonged chest pain that is suggestive of impending myocardial infarction. Since the patient experienced prolonged chest pain, she should be admitted to the telemetry floor for further examination and treatment.
3. The cholesterol level of the patient should be accessed and monitored carefully, and upon her discharge, she should be advised of the best weight loss and exercise program. If her level of cholesterol is high, cholesterol- lowering medication should be prescribed.