Download FLORENCE BLACKMAN iHUMAN 49-YEAR-OLD FEMALE PRESENTS WITH “INTERMITTENT SQUEEZING CHEST PA and more Exams Nursing in PDF only on Docsity! NURS 522 FLORENCE BLACKMAN iHUMAN 49-YEAR-OLD FEMALE PRESENTS WITH “INTERMITTENT SQUEEZING CHEST PAIN”. Date of Visit: July 6, 2022 Patient Name: Florence Blackman Patient Age: 49-year-old Subjective Chief complaint: Florence Blackman is a 49-year-old female with a past medical history significant for hypertension and hypercholesterolemia who presents today for complaints of “intermittent squeezing chest pain”. HOPI: The patient is a 49-year-old female who presents to the clinic with complaints of intermittent midsternal chest pain that started two weeks ago. She describes it as a moderate 6/10 “squeezing” pain which radiates to the left arm and is worse with exertion. The patient also reports dyspnea associated with the episodes of chest pain and worsening pain in the cold weather. The pain and shortness of breath has a sudden onset and is only alleviated by rest which sometimes interferes with her ability to do cross-country skiing in the winter. Patient denies any fatigue, fever, chills, nausea, vomiting, sleeplessness, or abdominal discomfort. She denies any allergies or use of over-the-counter prescription medications or herbal supplements to help with symptoms. She reports a past medical history of hypertension for which she is taking 12.5 mg of hydrochlorothiazide daily and hypercholesterolemia which she is attempting to manage with diet changes. The family includes stroke and coronary artery disease. The physical examination is normal, except for a BMI of 25.5. History: Medical: • Hypertension diagnosed 2 years ago • Hypercholesterolemia diagnosed 1 year ago, currently uncontrolled Surgical/Hospitalizations: • No past surgeries, trauma/injuries, or hospitalizations Family Hx: • Biological father (deceased): stroke at age 65 • Biological mother (deceased): heart disease at age 54 • Biological sister (living): Recent open-heart surgery at age 58 Social Hx Diet: • Frequently eating fast food and restaurant meals Exercise: • High-intensity aerobics class three times per week Occupation: • Marketing executive with own firm that is demanding and requires long work hours Home Environment: • Patient lives independently in a loft and reports being in a safe environment Tobacco: • 5-year history of cigarette smoking, but quit 15 years ago • Denies use of chewing tobacco or other tobacco products Recreational drugs: • Denies recreational/illicit drug use Alcohol: • Reports drinking 1 – 2 glasses of wine a day • Denies excessive alcohol consumption or history of alcohol abuse Sleep: • Denies falling or staying asleep Leisure activities/stress reduction: • Cross-country skiing with friends in the winter to help with work-related stress Allergies: No known allergies Medications: 12.5 mg PO hydrochlorothiazide once daily Vaccines/Immunizations: Up to date on immunizations Preventative Health: Regularly visits primary care provider to monitor cholesterol and blood pressure ROS: Constitutional: Reports being in generally good health overall despite episodes of chest pain and dyspnea for the past two weeks and a reported history of hypertension and hypercholesterolemia. Denies any fever, chills, fatigue/weakness, night sweats, and unintentional weight loss or gain. Reports that her weight has been steady, but understands she is slightly overweight and needs to lose weight. HEENT: Denies runny nose, nasal congestion, or sore throat. Denies recent vision or hearing changes. Denies any difficulties swallowing or jaw/neck pain. Respiratory: Reports worsening dyspnea associated with chest pain, which is alleviated with rest, as well as dyspnea with exertion. Denies history of lung disease or any allergies. Denies nocturnal dyspnea, orthopnea wheezing, difficulty catching breath, or cough/sputum production. Cardiovascular: Reports a history of mild hypertension for which she takes 12.5 mg of hydrochlorothiazide once daily and hypercholesterolemia. She also reports an intermittent squeezing chest pain and dyspnea on exertion typically lasting a few minutes for the past two weeks, especially in the cold weather when she is cross-country skiing. The pain is in the center of her chest, and she rates it as a moderate 6/10. She denies any exercise intolerance and is able to attend a high-intensity aerobics class three times a week despite current symptoms. Denies any palpitation, syncope, or history of irregular heartbeats. Gastrointestinal: Denies nausea, vomiting, constipation, diarrhea, coffee ground emesis, dark tarry stool, bright red blood in bowel movements, early satiety, or bloating. No abdominal pain reported. Musculoskeletal: Reports that the chest pain radiates to left arm. Denies pain, weakness, or swelling in any other extremities or joints. Peripheral vascular: Denies any extremity edema or lower extremity pain. Objective Vitals:
