Case Study Analysis: Norman Golding's Health History and Treatment

This case study presents the health history of Norman Golding, a 38-year-old male with a history of hypertension, who presented with chest pain indicative of a myocardial infarction. The document includes detailed biographical data, source and reliability information, and the reason for seeking care. It meticulously outlines the history of the present illness, past health history (including childhood illnesses, immunizations, allergies, transfusions, and hospitalizations), family and personal history, lifestyle habits, present environment, financial stability, psychosocial aspects, and a comprehensive review of systems. The case study also provides a genogram, a detailed physical assessment, and a functional assessment, including education, financial status, values and belief systems, self-care behaviors, activities/exercise, sleeping patterns, nutrition/elimination, interpersonal relationships, and coping mechanisms. The formulation summarizes the patient's condition, leading to an impression of hypertension and acute anterolateral myocardial infarction, and a treatment plan including serial physical examinations, medication management (aspirin, nitrates, heparin, ACE therapy), and further investigations such as an echocardiogram. The case study concludes with references to support the information presented.

Running head: HEALTH HISTORY 1
Health History
Name
Institution

HEALTH HISTORY 2
Health History for Norman Golding
Date: 7:10:2017
Examiner: Dr. Mell Banks
1. Biographical Data
Name: Norman Golding
Birth Date: 11.11.1979
Age: 38
Gender: Male
Place of Birth: Texas, USA
Marital Status: Married
Race/ Ethnic origin: White
Telephone number: [phone]
Occupation: Mechanical Engineer
Employer: Government parastatals
2. Source and Reliability
Patient, who is reliable as well as the hospital's records
3. Reason for Seeking care
The admission will be the second so far for Norman who has a history of hypertension.
The patient complains of chest pain lasting for 12 hours.
4. History of present illness
Norman has a long history of a condition known as hypertension. The condition is
normally controlled through diuretic therapy. His first admitted was in 1998 with complaints of
internal mid-sternal chest pain. The X-ray conducted on him indicated mild pulmonary

HEALTH HISTORY 3
congestion with cardiomegaly. He was discharged following a series of treatment in the hospital
like Lasix and digoxin for congestive heart failure. Since that time, his medical record has been
closely followed by his cardiologist.
The patient was well until 8 pm yesterday night when he noticed the onset of an aching
pain in his chest while helping his wife with minor duties. He described the pain like a toothache
like and it was noted to increase with exertion. No other symptoms were indicated. He took two
tablespoons of antacid but did not get any relief, the pain gradually increased. After roughly six
hours, his wife gave him an aspirin and brought him to the emergency room. The
electrocardiogram indicated sinus tachycardia at 110 as well as occasion ventricular paroxysmal
contractions. He was immediately placed on thrombolytic therapy and cardiac medication.
The current treatment includes Tylenol 2 tabs daily, Enalapril 20mg twice daily, Digoxin
0.125mg once daily and Lasix 40mg once every other day.
5. Past health history
General health: The general health description can be considered as relatively good.
Childhood illness: Norman had usual childhood illnesses
Immunizations: Flu vaccine yearly
Allergies: Allergic to penicillin. This was developed after an injection 15 years ago and
reacts through causing a diffuse rush.
Transfusions: 3 units received in 1990 for GI hemorrhage, the transfusion complicated by
a Hepatitis B infection
Previous hospitalization: 1994 Gastrointestinal hemorrhage and in 7/1998 chest pain
6. Family and Personal History
Norman Golding is lives with his wife and daughters in Texas.

HEALTH HISTORY 4
He works as a mechanical engineer in a local government firm
Lifestyle habits: Does not take alcohol or cigarettes.
Follows a strict diet
He has never been outside the United States
Present environment: Normal lives in a three-bedroom apartment on the third floor.
Financial stability: Norman is financially stable and has medical coverage insurance
Psychosocial aspect: Generally, Norman is an alert and active man despite his condition.
Family history:
The mother of the patient died at the age of 34 from diabetes, and hence he was brought
up by his aunt. His father died following a car accident at the age of 56. The patient also had a
sister who died nine years ago as a result of seizures and pneumonia and another brother who
died in childbirth. Norman has three daughters (ages 16, 12, 10), his daughters are all healthy.
His background check shows a history of heart-related diseases as well as diabetes.

HEALTH HISTORY 5
Genogram
7. Review system
General overall health state: A well-developed man, slightly obese white man with
complaints of chest pain
Skin: Fair skin with no symptoms of any complications, skin warm and smooth
Hair: Brunet
Nails: Normally aligned nails
Eyes: Extra ocular motions full, conjunctiva clear, pupils equal round and is also reactive
to light. Fundi not well visualized credited to the possible presence of cataracts.
Ears: Tympanic membrane landmarks well visualized and hearing average bilaterally
Nose: no evident obstruction, septum not deviated as well as any discharge
Mouth and throat: A complete set of lower as well as upper dentures. Uvula moves up in
the midline as well as a normal gag reflex. Pharynx not injected
Neck: no masses, thyroid not palpable and jugular venous pressure 9cm

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Chest: No cases of masses or discharges recorded, any dullness to percussion, the
diaphragm and respiration move in unifortimity, and there are no signs of rhonchi wheeze or rub.
Respiratory: PMI at the 7th ICS, 1.5 cm lateral to the MCL, slight presence of heaves and
thrills. Regular heart rhythm with extra beats occasionally. Normal S1 and S2: Positive S4
gallop. The pulses are noticeable for carotid upstrokes
Spine: mobile, mild kyphosis
Abdomen: liver span 13cm by percussion, tender to palpation, bowel sounds present,
liver edge, soft, flat
Pelvic: could not be assessed until the patient is stable.
Neurological: motor, the strength of the patient is average and the patient can move all
the extremities, reflexes: symmetrical 1+ throughout, awake, alert and fully oriented, sensory:
grossly normal to touch and prick.
Rectal: stool obtained is brown, negative for blood. Prominent external hemorrhoids
8. Function assessment
Education: Major Bachelor Science Degree in Mechanical Engineering, 2006- 2012, New
Mexico State University-Degree in English and Literature, 2013-2014, University of Delaware
Financial status: Considering his profession, Norman is financially stable and has
multiple medical coverages for himself as well as his family. His wife is a professor and a
Medical school in Illinois, and hence his family lives a very comfortable life.
Value and belief system: Norman has strong Christian values; the same is reflected
through his family. Most of the time, his decisions are embedded on a Christian moral compass

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and hence is rigid to things that he may individually consider as unethical. His strong Christian
values explain why he does not engage in alcohol drinking and cigarette smoking.
Self-care behaviors: The patient’s self-care activities are very impactful; they include
medication adherence- this includes strict adherence to taking his blood pressure pills at the
stipulated time. Physical activities- Norman sets aside 30 minutes every day for physical
activities like swimming and walking, low salt diet- his food is normally low in salt content as
recommended by the doctors, as well as eating healthily.
Activities/ exercise: Swimming, 20-30 minutes’ walk every day, jogging with members of
his golf club once per week and engagement in other physical exercises
Sleeping pattern: The patient has normal sleeping patterns of about 10-12 hours daily. He
does not have any signs of insomnia regarding sleeping patterns
Nutrition/ elimination: The patient has a very strict diet that is characterized by low fat
and salt content. His diet is also comprised of several vitamins that are normally issued in
between his main meals. The medical history of the patient points out that the long duration of
hypertension has indeed shaped his eating habits and hence generally affecting the quality of the
nutrition structure.
Interpersonal relationship/ resources: Norman has a laid back and shy personality. The
same explains why he has a normal interpersonal relationship with his coworkers.
Intimate partner violence: No reported case of intimate partner violence. Mrs. Golding is
happy in her marriage and reports a good relationship between her and the husband. The kids
also have a healthy relationship with their father.

HEALTH HISTORY 8
Coping and stress management: The patient uses two coping and stress management
techniques that have worked out well for him: Progressive Muscle Relaxation and Autogenic
training
Personal habits: The patient employs self-care techniques that work out well for him; this
is reflected in his personal habits of a free alcohol and cigarette lifestyle through the years.
Subsequently, this personal habit has placed him at an advantaged position when compared to
other patients with a similar condition that but who engage in alcohol consumption. His stress
response technique and physical activity performance are also essential components in the
process of the treatment that has been managed well.
Environmental hazards: The immediate environment of the patient both at home and at
work is conducive for such patients since they are stress-free.
Occupational health: Responsible and does not let his health condition interfere with his
work.
Perception of own health: Despite his condition, Norman has a positive attitude towards
life and believes that he can achieve all the things that a healthy person can achieve. He looks at
the positive side of things like how the conditions have taught him the importance of living
healthily rather than how it has drained him.
Formulation
Norman’s family history indicates a channel of heart diseases. In relation, he has a history
of congestive heart failure as well as artery disease risk factors of hypertension. His examination
pointed out that there is sinus tachycardia with no JVD but present bibasilar rates suggesting
congestive heart failure. Lab reports also show the elevation of CPK as well as troponin.
Impression

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Hypertension
Acute anterolateral myocardial infarction credited to the complication of the mid-left
ventricular dysfunction. The patient has been subjected to thrombolysis therapy
Treatment plan
 Follow serial physical examinations; continue taking aspirin, nitrates, heparin and
nasal oxygen.
 Continue ACE therapy to aid in monitoring blood pressure
 Bacterium treatment for any complications in the unitary tract such as urinary
infection and follow this up on urine culture results
 Obtain echocardiogram to examine post-MI heart function on the cardiac exam. If
the LV ejection is pressured, beta-blocker therapy should start early.
Norman’s condition can be effectively handled through a comprehensive channel of
medical treatments as well as a strong support system. Therapy sessions and the support of his
family will in a big way aid this process (Dibona, 2013).

HEALTH HISTORY 10
References
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560.
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care. The Journal of cardiovascular nursing, 29(3), E11.
Han, H. R., Song, H. J., Nguyen, T., & Kim, M. T. (2014). Measuring self-care in patients with
hypertension: A systematic review of literature. Journal of Cardiovascular
Nursing, 29(1), 55-67.
Hu, H., Li, G., & Arao, T. (2013). Prevalence rates of self-care behaviors and related factors in a
rural hypertension population: a questionnaire survey. International journal of
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Liza, V. (2011). Stress Management Techniques: evidence-based procedures that reduce stress
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mindfulness-based stress-reduction program and conscious yoga on lifestyle, coping
strategies, and systolic and diastolic blood pressures in patients with hypertension. The
Journal of Tehran University Heart Center, 10(3), 140.
Panda, S. (2014). Stress and health: Symptoms and techniques of psychotherapeutic
management. Indian Journal of Positive Psychology, 5(4), 516.
Rosendorff, C., Lackland, D. T., Allison, M., Aronow, W. S., Black, H. R., Blumenthal, R. S., ...
& Gersh, B. J. (2015). Treatment of hypertension in patients with coronary artery
disease. Hypertension, 65(6), 1372-1407.

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