Comprehensive Patient Assessment

COMPREHENSIVE PATIENT ASSESSMENT 1

Institution Affiliation

Patient Complaints

The patient, in this case, suffers from pulmonary hypertension and ison her seventh visit at the California Pacific Medical Center (PCMC)that offers a series of pulmonary and critical care programs. Thepatient is visiting the facility having experienced an acute chestthat has lasted approximately more than 18 hours. Due to the natureof pain she has been going through, she has decided to seek medicalattention.

History of the Patient

The patient’s name is known as Kristina Williams and she is 28years old. Since her late teenage years, she has been havinghypertension-related issues and as such has been a regular visitor tothe California Pacific Medical Center (PCMC). In the initial yearsfollowing the diagnosis of the medical problem, diuretic therapy wasused to control hypertension. She was first admitted to the hospitalin November 2007 after complaining of midsternal chest pains. Varioustests were conducted, and the electrocardiogram showed a first degreeantrioventracular block. On the other hand, the x-ray resultsindicated that there was a mild pulmonary congestion. Based on theresults obtained, myocardial infarction was ruled out. Additionally,the cardiac enzymes were also considered when the decision to ruleout myocardial infarction was made. To tackle the chest congestionproblem, the patient was put on a regimen of digoxin, enalapril, andlasix after which she was discharged.

Over the years, the patient has reaffirmed the fact that she onlysuffers from the hypertension problems and not any othercomplications. Her medical history indicates that there are no casesof coronary artery risk factors. As such, she is free from diabetesand hypercholesterolemia. There is no family history of heartdiseases or other forms of cardiovascular complications. According tothe patient, she experiences extreme fatigue after engaging in anyform of intense physical activity. The same pain was felt when thepatient stands at a spot for a substantial period. She therefore hadto extreme suffering since she has to move around a lot of times whencaring for her daughter. Additionally, her job requires her to bebased at a particular location for a substantial amount of time.

The patient had been in a relatively stable state recently before shestarted experiencing the acute chest pains that led to her admissionto the hospital. The pain was experienced specifically below herchest bone. Despite the reoccurrence of the pain, however, thepatient did not report the existence of nausea and palpitationssymptoms. Moreover, she did not suffer from dizziness or diaphoresis.To tackle the pain, the patient had taken a dose of an antacid beforeproceeding for a walk around the block. It is when taking the walkthat the intensity of the pain increased and she had to be assistedback home promptly so as to get a rest. When she got home, she tookaspirin tablets and went to her bedroom for a break with the hopethat the pain would subside. However, when she felt that thesituation was not changing, she requested to be brought to thehospital. On arrival, the patient was given cardiac medications.

Current Regimen

The patient is currently on various drugs, and they include Enalapril30mg that is taken thrice in a day, Kcl 20mg to be taken daily, andTylenol tablets that are taken daily for arthritis. Other currentmedication regimens for the patient include Digoxin 0.125mg that istaken once a day and Lasix 40mg once every other day (Ralph, Taylor,&amp Teton Data Systems (Firm), 2005).

Past Health

The following are details of the patient’s past health.

General: The patient has a relatively stable health withregards to the weight.

Transfusion: The patient has never had a blood transfusionbefore.

Immunization: The patient has had no form of vaccination forthe last three years. She is also allergic to penicillin.

Hospitalizations: The patient had a normal childbirth fiveyears ago and was also hospitalized in 2006 for a bout of malaria.Apart from these two instances, she has never been hospitalizedagain.

Systems Review

Dermatological: The patient has no pruitis

Rheumatic: The patient has no history of arthritis or gout

Emotional: No documented case of depression and anxiety

Endocrine: No existing thyroid disease

Hematological: The patient has never experienced any clottingdisorders.

Constitutional: The patient is relatively weak though theweight and height are within the standard limits.

Respiratory: The patient has no history of coughing andwheezing. No cases of asthma and tuberculosis have been reported inthe past

HEENT: The patient did not have a headache, there were noreports of eye pain, and the nose had no obstructions.

Neuromuscular: For the last seven years, the patient has beenhaving osteoarthritis of the right knee. Since then, she has beentaking acetaminophen to counter the complication.

Personal History of thepatient

  • Mrs. Katrina Williams is a single mother and lives with her son

  • She works as a receptionist at a hotel

  • She does not smoke or take alcohol. Moreover, she is on a diet following the recommendation by her nutritionist

  • The patient was born and brought up in Los Angeles where she has lived her entire life

  • She lives on the ground floor of a building located in Simi Valley. Due to her work schedule, she has a domestic helper to assist her in caring for her son

  • The patient receives social security and additional financial assistance in the form of child support

Family History

The patient is the last born in a family of four siblings. They werebrought up by both of their parents. The mother is widowed havinglost the husband through a road accident four years ago. She hasthree nephews and two nieces. The family does not have a history ofhypertension or cancer.

Physical Examination

Vital Signs: Temperature 100.1, regular pulse, and bloodpressure is 130/96

HEENT: The eyes are motion full and conjunctiva clear. Thepupils are normal and respond to light. The tympanic membranes of theear are well visualized. The nose has no discharge as well as noobstruction. There is a complete set of both the upper and lowerdentures with an average gag reflex. The patient is physically welldeveloped and has no signs of obesity. However, she experienceslittle difficulty in breathing.

Neck: There are no masses in the neck

Abdomen: Bowel sounds present. Additionally, liver edge andkidney are not felt.

Spine: No costovertebral tenderness

Pelvic: This was deferred till the patient was considered tobe in a stable condition

Extremities: The skin was warm and smooth with the onlyexceptions being witnessed in cases of chronic venous stasis in theright leg. However, there is no clubbing

Labs

CXR: portable AP, probably cardiomegaly, mild PVC

Formulation

The 28-year-old woman has a medical history that shows a highprobability of hypertension. Additionally, the patient has a historyof congestive heart failure and coronary artery disease risk factors.She also experiences chest pains whenever she engages in any form ofphysical activities. Tests have indicated that there is a degree ofcongestive heart failure. The laboratory results indicate an increaseof CPK whereas the acute anterolateral myocardial infarction ishighlighted by EKG changes.

Impression

  • Dysuria – 3+ bacteria in urine with pyuria

  • Hypertension

  • Acute anterolateral myocardial infarction, complicated by mild left ventricular dysfunction. Patient has received thrombolysis therapy.

Plan

  • The patient should continue taking aspirin as well as nitrates, nasal oxygen, and heparin. In addition to this, there should be extensive physical examinations and strict adherence to the EKGs and laboratory results (Heuer, Scanlan &amp Wilkins, 2014).

  • The patient should also consider obtaining an echocardiogram (Joint Commission on Accreditation of Healthcare Organizations, 2003). This will play a great role in the assessment of the functioning of the heart. On the other, the patient should embark on an immediate early beta block therapy in case the LV ejection fraction has been potted.

  • The patient should continuously monitor her blood pressure and maintain the ACE inhibitor therapy

  • The patient should also begin Bactrim treatment promptly. This is to assist in the management of presumed uncomplicated urinary tract infection. Moreover, she should follow up on the urine culture results. Since the patient is afebrile and lacks costovertebral tenderness, dysuria and pyuria-probable recurrent cystitis is applicable (Gehrig &amp Willmann, 2013).

References

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Gehrig, J. S., &amp Willmann, D. E. (2013).&nbspPatientassessment tutorials: A step-by-step procedures guide for the dentalhygienist. Philadelphia: Wolters Kluwer Health/LippincottWilliams &amp Wilkins.

Heuer, A. J., Scanlan, C. L., &amp Wilkins, R. L. (2014).&nbspWilkins`clinical assessment in respiratory care. St. Louis, Mo:Elsevier/Mosby.

Joint Commission on Accreditation of Healthcare Organizations.(2003).&nbspHospital patient assessment: Meeting the challenges.Oakbrook Terrace, Ill: Joint Commission Resources.

Ralph, S. S., Taylor, C. M., STAT!Ref (Online service), &amp TetonData Systems (Firm). (2005).&nbspNursing diagnosis referencemanual. Philadelphia: Lippincott Williams &amp Wilkins.

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