NR304 Assignment Paper: Health History and Physical Examination

Health History 2
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Health History 2
Health History and Physical Examination
Subjective data: health history
Demographic data: 45 year old, married Hispanic-American female. She is slightly overweight. Her name is Martha Bruni.
Reason for care: Martha Bruni is in the facility because of chest pain. She stated that she has been having chest pains for 7 straight days now.
Present illness: this is Martha Bruni’s first admission at the facility. She stated that she was in her normal good health state until 7 days before her admission, when she noticed a sudden onset of aching and dull chest pains. Since that first pain 7 days prior, she has experienced 2 more episodes of pain, each lasting about 12 minutes. This evening, Martha Bruni experienced an episode of pain that lasted 26 minutes, which lead her to visit the facility.
Perception of health: individual considers herself relatively healthy but notes that her hypertension is controllable, and her chest pains are getting worse.
Past medical history: Martha Bruni has taken several medications in the past for various illnesses. In 2000, she was diagnosed with peptic ulcer disease that was successfully treated using cimetidine medicines. In 2005, she was diagnosed with high blood pressure and started using unknown medicines. Due to drowsiness, she stopped the drugs after only 7 months. The individual is allergic to penicillin. She has not been vaccinated/immunized as an adult.
Family medical history: positive family history of high blood pressure/hypertension. Mother is deceased having died of heart attack at the age of 61. Martha Bruni has no sisters or brothers. Father is 77, alive and well.
Review of systems
Developmental considerations: patient is middle-aged, female.
Psychosocial considerations: no depression and social stigmatization.
Cultural considerations: culturally competent patient care is necessary for this Hispanic individual.
Collaborative resources: the individual has collaborative resources which include her family members comprising husband aged 46 and two daughters aged 26 years and 23 years, the community, groups and even the health care system (Jarvis, 2011).
Objective data: physical exam
HEENT (head, eyes, ears, nose and throat): scalp is normal. Nasal mucosa is normal. External auditory canals and tympanic membranes are normal. Gums and tongue normal. Pupils are equally round, 4 mm. Pupils are reactive to light.
Neurological system: Martha Bruni has normal cranial nerves II-XII. Sensory and motor exam of lower and upper extremities is normal. She has normal reflexes. Gait and cerebellar function is normal.
Neck: can be moved easily without resistance. Thyroid gland normal with no masses. Trachea is midline. Carotid artery upstroke is normal bilaterally. Lymph nodes are normal. No lymphadenopathy.
Respiratory system: no obstructive sleep apnea, no bronchial asthma.
Cardiovascular system: essential hypertension. No obesity-associated cardiomyopathy. No coronary heart disease.
Gastrointestinal system: Martha Bruni has no nausea, dysphagia, or change in stool color, consistency or pattern. She has epigastric pain, the pain is burning...