History and Physical Comprehensive Assessment Assignment Sample

• Subject Name : Nursing

Substernal Chest Pain and Dyspnea in A Female Patient

Introduction to History and Physical Comprehensive Assessment

Unstable angina can also be commonly known as heart-related chest pain. This pain in patients can be observed to be radiating to other body parts such as shoulder, neck and arms. The pain is mainly brought about due to inadequate or insufficient supply of blood to the heart muscles. This deprives the heart of oxygen supply (Puelacher, 2019). Unstable angina can develop in patients due to exertion or stress and even in a state of rest. With the advancing frequency the pain worsens and the severity also increases, bringing about acute discomfort for the patient. It can be an emergent situation requiring critical level care.

Unstable angina also makes up for the primary cause of development of coronary heart disease. This is brought about by build-up of plaque in the arterial walls. It makes the arteries narrow and rigid over the due course of time and thus, limiting the blood flow through the same. Due to hampered blood flow, there is an additional pressure exerted on the heart muscles, making it feel like a chest pain for the patient. it may or may not be marked by increased shortness of breath in the patient (Krishnan, 2017).

Unstable angina in elderly patients is a big risk factor, with an advanced prevalence of development of coronary risk factor. It is one of the most intensive risk factors that calls for urgent lifestyle modifications for minimising the harm of the condition to the patient, upon its clinical manifestation.

Chief complaints- The patient has been feeling a bit nauseous for the past three days. She has also been experiencing shortness of breath. She reports about her back aching and feeling more tired than on usual days. She finds herself incapable of attending Pilates class because of her lethargy and feeling of uneasiness.

History of present illness- The case study is of a 74-year-old Caucasian female. She is married and retired from her job where she worked as a dental assistant. She has been reported to be in good shape of health most of her lifespan. She has a physically active routine as well. She follow-ups with her general practioner two times in a year. She is also having history of skin carcinoma for which she pays visit to a dermatologist, twice a year. Due to her current concerns, she has been feeling a delay and slowness in her activities of daily routine. She has been observing this pattern since the past three weeks.

Past medical history- Patient is having a past medical history of Osteoarthritis and Malignant Melanoma.

Past surgical history- The patient underwent the surgical resection of malignant melanoma of the left anterior lower leg at the age of 45 years old.

Social history- Patient has a current history of intake of a glass of wine along with her meals. She takes 5 glasses per week. She also has a history of smoking, which she started doing at the age of 16 years. She used to consume 10 cigarettes per day. However, she ending up quitting smoking at the age of 35 years.

Medication history- She is taking paracetamol PRN and Caltrate +D plus.

Allergies- The patient is not having any underlying allergy to any elements such as foods, insect bites, environmental allergies and so on.

Review of systems- The review of system as noted in the given clinical case study include the following:

1. General- Patient complaints of feeling very lousy and having lack of energy to do anything.
2. Respiratory- The patient is having a marked shortness of breath since the last three days.
3. Cardiac- Patient is experiencing recent chest pain and is having a restricted physical movement.
4. ENT- nothing abnormal detected.
5. Throat and neck- Nothing abnormal detected.
6. Gastrointestinal- Denies of any abnormal bowel movement.
7. Neurological- Denies of any abnormal neurological deficit.
8. Urinary- Nocturia present. Patient denies any presence or history of urinary tract infection.
9. Endocrine- No history of any disease.
10. Hematology- Patient denies of any history of anemia or bleeding disorder.

Physical examination-

• Vitals- Heart rate is observed as 88 beats/ minute, respiratory rate is observed as 24 breaths per minute, blood pressure is observed as 148/55 mmHg, which is indicative of hypertensive blood pressure. Patient is able to maintain oxygen saturation at 98% on room air. Patient is also having a normal body temperature of 37 degree Celsius.
• General- The patient is looking reasonably healthy, with mild facial pallor noted for the patient.
• HEENT- There was no abnormal clinical signs noted for the patients.
• Neck- No abnormal signs were observed for this section of the patient.
• Cardiovascular- The patient is having a heart rate of 88 beats/minute. There were no abnormal heart sounds observed in the patient. Bilateral breath sounds were observed to be clear.
• Lungs- The breath sounds are clear. No adventitious breath sounds were observed in the lung fields.
• Abdomen- There was no palpable mass observed in the abdominal region. No abnormal bowel sounds were observed for the patient.
• Gastrointestinal- No abnormal findings detected.
• Extremities- Normal pulses were observed in bilateral extremities. No other abnormal sign detected for the patient. The patient was observed to have arthritic changes with ulnar deviation observed in hands. There was a mild swelling and crepitus present in bilateral joints. Range of motion was marginally decreased in bilateral hip and knee, due to arthritis changes.
• Neurological- Patient was found to be alert and oriented to time and place. She was aware of her surroundings.
• Psychiatric- Patient is in sound mental health and denies of presence of any signs of depression or anxiety.

Lab findings- The abnormal lab findings present for the patient includes high cholesterol levels.

Diagnostic findings-

• Chest X-ray- Reflects on no signs of abnormality.
• ECG- It also reflects on presence of normal sinus rhythm with no abnormalities noted.

Assessment-

Patient in the given case study is 74-year-old female. The patient is physically active and has been feeling nausea and shortness of breath for the past three days. She is also having back pain and feels more tired than usual. Patients vitals are within normal range on observation. However, her blood pressure is on the hypertensive side. She is alert and oriented to the time and place and is able to respond well. She has been diagnosed with osteoarthritis and malignant melanoma, for which she is taking regular treatment and follow-ups with her general practioners. There are no abnormal breath sounds and heat sounds observed for the patient. ECG and X-ray conducted reflected upon normal findings. The lab reports however, suggest high levels of cholesterol, which can be a risk factor for developing unstable angina.

Differential diagnosis-

1. Unstable angina
2. Acute coronary syndrome
3. Osteoarthritis
4. Hypertension

Plan-

• Shortness of breath- It can be examined with the help of chest Xray to further determine the cause. The patient can be taught breathing exercises to compensate for the respiratory loss. The patient can also be provided with oxygen therapy to manage the shortness of breath and enhance comfort for the patient (Cadet, 2019).
• Pain- The pain in the back can be due to radiation observed due to unstable angina. Patient can be provided with mild pain medication to subside the symptoms.
• Hypertension- Patient can be advised on intake of low salt diet. Medications for correction of hypertension can also be provided to the patient (Tocci, 2019).
• High cholesterol level- The patient can be advised on a dietary plan which will help in maintaining a healthy eating lifestyle. This will be helpful in reducing the negative impact caused by probable high cholesterol levels.
• Patient education- With the advancing age the patient is at a higher risk of again developing the acute attack of unstable angina. The patient can be educated on the lifestyle modifications to be incorporated in the daily routine to minimize the risk and prevent another episodic event (Stolic, 2019).
• Follow-up- The patient can be advised on getting a follow-up with the general physician for keeping a close vigil on the development of her condition. This can be monitored through regular lab testing and diagnostic techniques such as ECG, X-ray and so on. It will help in early detection and early prevention of any abnormal signs and symptoms in the patient (Kourbelis, 2020).

References for History and Physical Comprehensive Assessment

Cadet, M. J. (2019). Substernal chest pain and dyspnea in a female patient. The Journal for Nurse Practitioners, 15(3), 65-68. https://doi.org/10.1016/j.nurpra.2018.11.001

Kourbelis, C. M., Marin, T. S., Foote, J., Brown, A., Daniel, M., Coffee, N. T., ... & Nicholls, S. (2020). Effectiveness of discharge education strategies versus usual care on clinical outcomes in acute coronary syndrome patients: A systematic review. JBI Evidence Synthesis, 18(2), 309-331. http://dx.doi.org/10.11124/JBISRIR-D-19-00042

Krishnan, S., Otaki, Y., Doris, M., Slipczuk, L., Arnson, Y., Rubeaux, M., ... & Tamarappoo, B. (2017). Molecular imaging of vulnerable coronary plaque: A pathophysiologic perspective. Journal of Nuclear Medicine, 58(3), 359-364. http://dx.doi.org/10.2967/jnumed.116.187906

Puelacher, C., Gugala, M., Adamson, P. D., Shah, A., Chapman, A. R., Anand, A., ... & Wildi, K. (2019). Incidence and outcomes of unstable angina compared with non-ST-elevation myocardial infarction. Heart, 105(18), 1423-1431. http://dx.doi.org/10.1136/heartjnl-2018-314305

Stolic, S., Lin, F., & Mitchell, M. (2019). Randomized controlled trial of symptom management patient education for people with acute coronary syndrome. Journal of Nursing Care Quality, 34(4), 340-345. DOI 10.1097/NCQ.0000000000000383

Tocci, G., Figliuzzi, I., Presta, V., Miceli, F., Citoni, B., Coluccia, R., ... & Volpe, M. (2018). Therapeutic approach to hypertension urgencies and emergencies during acute coronary syndrome. High Blood Pressure & Cardiovascular Prevention, 25(3), 253-259. DOI https://doi.org/10.1007/s40292-018-0275-y

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