7100NRS Trimester 1: Health Assessment and Analysis Report

This report presents a detailed health assessment and analysis of a 76-year-old retired bank official, Mrs. Amelia Kale, focusing on her presenting problem of chest pain. The report includes a comprehensive review of her history, including previous diagnoses of hypertension and presumed congestive heart failure, current medications, and lifestyle factors. Key findings from the physical examination, such as vital signs, head-to-toe assessment, and auscultation results, are meticulously documented. The analysis critically evaluates the findings, referencing relevant literature to understand the potential causes of the patient's chest pain, including the possibility of myocardial infarction and the impact of hypertension. The report synthesizes the information to determine health priorities, such as managing blood pressure and continuous monitoring, and justifies these priorities based on the patient's condition and potential risks. The report also includes a discussion on the importance of cholesterol tests and heart murmurs, and their relation to the patient’s condition.

HEALTH ASSESSMENT
AND ANALYSIS
Student name –
University name –

Patient profile
 Mrs. Amelia Kale is a 76-year-old retired
bank official with prolonged diuretic
therapy for hypertension

Presenting problem
 Beginning of "throbbing pain under her
breast bone" while sitting and staring at
the television
 The agony was depicted as "substantial"
and like "toothache"

How the patient described the symptoms
 It was not noted to emanate, nor
increment with the application of exertion
 She denied vomiting, nausea, palpitations,
diaphoresis, and loss of awareness or
dizziness
 She denies paroxysmal nighttime dyspnea,
syncope or ongoing chest pain

History of presenting problem
 Admitted to emergency clinic in May, 2019
complaining of discontinuous midsternal chest
pain
 electrocardiogram and chest X-ray demonstrated
first degree atrioventricular block, and a gentle
aspiratory blockage with cardiomegaly

History of presenting problem
 Daily routine of enalapril, and lasix, and
digoxin, for assumed congestive
cardiovascular failure was administered
 Regular follow-up with cardiologist
 Two-pillow orthopnea observed after admission
 Two blocks strolling causes dyspnea
 Delayed standing causes mild, chronic ankle
edema.
 No history of rheumatic fever, diabetes and
cardiovascular illnesses.

Key findings
 Blood Pressure was 170/90 mmHg
 Temperature was 99 degree
 Respiration Rate was 25 breaths per minute
 Heart Rate was 81 beats per minute
 Pulse was at 94 beats per minute.
 The pupils equally rounded and heavily
reactive to light

Key findings
 The patient had a hearing problem;
however, landmarks of tympanic
membrane were well visualized.
 There was no discharge or sputum
observed from the nose of the patient.
 When the mouth area was tested,
complete set of lower and upper
dentures are observed and a normal
reflex of gag was also observed.

Key findings
 No wheezing sound or difficulty in breathing
was observed during chest examination and
the diaphragm moved well during respiration.
 A systolic ejection murmur in grade II / VI is
detected without radiation at the left upper
sternal boundary.
 Pulses are noted for sharp upstrokes in the
carotid.
 No thrills or heaves with a regular rhythm
have been observed during the check.

Key findings
 Warm skin because of the high temperature
recorded
 1+ edema was observed to the knees
which are also very tender to palpation.
 No cyanosis or clubbing was observed.
 The patient was awake, fully oriented and
alert.
 Except for reduced hearing, the cranial
nerves III-XII are intact.

Key findings
 During the rectal examination,
prominent hemorrhoids have been
observed and felt externally
 However, the stool was brown in color
and did not count for blood.
 No history of pleurisy, wheezing, cough,
asthma, pulmonary emboli, hemoptysis,
pneumonia, TB or TB presentation.

Importance of assessments
 The first thing that was assessed were the
vital signs which included temperature,
pulse, respiration rate, heart rate and blood
pressure
 The head, ears, eyes, nose and throat
examinations were conducted
 No history of diabetes, hence no test for
blood glucose levels
 Patient was unstable because of which
pelvic examination was not conducted