Comprehensive Patient Assessment: Current Health Status

Comprehensive Patient Assessment
Student’s Name
Institutional Affiliation
Comprehensive Patient Assessment
Introduction
Rodgers Marlene is a female patient who was referred to the emergency department on 6th January 2017 in the evening after the nurse at the reception centre considered her illness being critical and that needed an urgent attendance. She is admitted for a week. The chief complainant presented by Rodgers is deep chest pains which according to her report began a couple of weeks ago. Initially, Rodgers thought that it was due to a cold exposure and that she did not seek medical care immediately since she thought that it would disappear after some time if she kept warm. Her background was also a derailing factor that made her not to seek medical care early in the time since she did not have a convenient means to the healthcare facility and further she lives alone. She comes from a poor family background.
General Patient Information
Rodgers is an elderly woman aged 66. She is a resident of Mississippi State. Rodgers is an African American, and she is black by race. As noted earlier, she is a single woman who lives alone. This came after her husband died about ten years ago after suffering a heart attack at the age of 58.
Current Health Status
Rodgers was admitted to the emergency department for the first time. She explains that her health situation was at normal and usual state before three weeks ago when the illness got worse prompting her admission in the hospital. During that time, the patient became aware of a hasty onset (over a couple of seconds to a minute) of chest pain. She explains the chest pain as being an aching and dull experience. She first felt the pain from her left parasternal section of the chest before it radiated up to the neck area. The first pain occurred to her when she was working on her garden early in the morning when it was still cold. She explains that she had been weeding her vegetables for approximately an hour when she began to feel exhausted before the pain erupted. She could feel shortness of breath. On interrogation, she denies any cases of vomiting, sweating or nausea. She approximates that the pain lasted between 8 and 15 minutes. The pain resolved after she decided to take a rest in her house.
Since that first pain three weeks ago, Rodgers has had three more additional episodes of pain which are similar and equivalent to the former regarding the area of infection and the quality. A week ago, she had a 10-minute episode of pain when she was walking with her pet dog. The pain resolved when she took a rest under a tree shade. Today in the afternoon, the woman experienced an episode of pain that lasted for an unusual longer period she estimates to be about half an hour. She had been taking an afternoon nap before she was awakened by a critical pain that prompted her to visit the medical facility. She has never tried out any treatment measure to her illness other than the deep rest. She states that there were no other symptoms associated with the illness during the three episodes. She denies symptoms such as palpitations and dizziness. She ran short of breath during the episodes but did not experience any orthopnea, exertional dyspnea or paroxysmal nocturnal dyspnea. She also denied any association with the pain with food, movement or GERD. She has never been diagnosed with any heart problem before. She has never had a chest pain either and does not have claudication. However, three years ago she was diagnosed with HTN.
Rodgers does not smoke. She is not diabetic. Three years ago, she was reported to be having hypertension. Six years ago, she had a TAH with BSO. She is not certain of her cholesterol levels, but her family history suggests a history of premature CAD. The patient is not currently under any hormone replacement.
Past Medical History
In 2012, she underwent a surgical treatment of bilateral oophorectomy for uterine fibroids and total abdominal hysterectomy. In 2013, she was diagnosed with hypertension and resorted to unknown medication. She, however, stopped such medication after an experience of drowsiness as a side effect of the drugs. Back in 2010, the patient the patient was reported with peptic ulcer disease. The thyroid resolved three months later after undertaking cimetidine medication. The patient has had no history of lung disease, cancer or coronary disease.
The patient describes of an allergy that occurred to her in 2005 after taking penicillin. She experienced rash and hives. No food and environmental allergies reported by the patient.
Personal Social History
The patient only acquired elementary education and had largely been relying on his husband's income before he passed on about ten years ago. Since then, she has been engaging on the cultivation of vegetables on her small garden and selling to the neighbours to raise her livelihood. She has been experiencing for economic conditions since her husband died. She has been struggling to meet her needs since the current income is low and not properly sustaining.
Rodgers had a good relationship with her husband and at no point was she assaulted or experienced any domestic violence. She had never experienced any sexual assaults before. Her garden is sometimes dust, and she is exposed to a lot of dust as she does the cultural activities in the garden. She also struggles with some cold in the morning when she has to water the crops before the sun during summers.
Earlier when her economic situation was fair, she used to take 1-2 bottles of beer every weekend and a glass of wine occasionally with meals during the week. She does not use tobacco. She has no history of illegal drug abuse.
Family history
Her mother is aged 79 while the father died at 56 of a heart attack. She ha...