The patient is 28-years-old and is of Mexican descent. She is female, and her marital status is single. She lives in Upland with her boyfriend. However, her birthplace is at West Covina. The patient graduated high school and worked as a Licensed Vocational Nurse (LVN). Her education can be described as advanced level. The birthplace of her parents is at Duarte, CA.
Source of Information and Reliability
The patient was reliable and provided all the information with any form of fear. She did not hesitate, and most importantly, she was fluent enough not to warrant the need for an interpreter.
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Reason for Seeking Health
Severe headache characterized by confusion, chest pain, difficulty breathing, and a throbbing heart.
Patient History
The patient has, in the past, been diagnosed with high blood pressure. However, on arrival at the emergency department, she says, "After I began feeling well, I have not considered using the drugs because I thought the disease was gone." From a proper look at her medical records, she has been hospitalized on many occasions due to the tendency of non-adherence to her medication. At the time of her admission, the patient was on Lisinopril. Siu (2015) asserted that Lisinopril is one of the most commonly used hypertensive drugs. According to the patient’s boyfriend, she has shown signs of confusion in the recent few days. Furthermore, she has complained of chest pains and a throbbing heart that does not seem to stop. She has difficulties in breathing, especially at night. Most significantly, the patient has also complained about chest pains, which have since prevented her from engaging in heavy duty. From the outlook, the patient is obese. However, from the boyfriend, she has hardly engaged in any exercise, especially in the last three months. The boyfriend said, “Although she has had a touch for exercises, her duty won’t allow her because she is literally busy working the whole day.”
Past Health
Childhood Illnesses
History of streptococcus throat adolescent 9-13 about two to three times a year.
Accidents or Injuries
No
Serious or Chronic Illness
Vertigo because of miners
Dx: A Magnetic Resonance Image (MRI) test was performed to confirm the presence of vertigo. Individuals with vertigo experience spinning dizziness. It primarily occurs when there is a problem with the inner ear, sensory nerves, or the brain (Lee, 2014). Some of the symptoms that the patient exhibited include motion sickness, nausea, vomiting, and a general feeling of faintness (Brandt, 2013). The patient underwent balance therapy and psychotherapy, and the problem eventually vanished.
Operations
One operation when she was four years old for correction of iris malformation. On a keen assessment of the eyes, there is a scar showing that the patient had indeed undergone the procedure in the past.
Review of Systems
General Health
The patient is weak and cannot stand on their own. She is complaining of chest pains, meaning that she requires quick intervention using the analgesics. Other than malaise, she looks tired and agonizing. From the general outlook, it is apparent that the patient needs admission into the emergency unit (Muhm et al., 2013).
Integument
Dryness and the redness of the face
Head
The head is okay without any major concern. The only notable aspect is the scar on the eye that signifies that the patient had undergone surgery on her left eye to correct the iris malformation that occurred when she was four years.
Neck
The neck does seem to be stiff and cannot easily rotate. This could be due to the immense chest pains that have since extended to her neck region . She also requires support on her neck region to speak properly.
Ears
Her ears do not seem to have any problem. She hears everything well and responds appropriately to the sounds.
Oropharynx
The patient does not have any notable problems with her oropharynx.
Respiratory
As indicated earlier, one of the reasons why the patient came to the hospital was due to her inability to breathe well. This could be due to the poor functioning of the lungs secondary to the heart problems she has.
Breasts
The patient does not have any problem with her breasts.
Gastrointestinal
The patient has not reported any problem to do with her gastrointestinal region.
Genitourinary
No problem has been reported to affect the region .
Reproductive History
The patient does not have any child. Also, from her history, she has not had any problem affecting her reproduction. It, however, shows that she is on contraceptives that run for three months.
Musculoskeletal
Due to the overbearing pain, the patient has pain in most parts of her joints, which have essentially inhibited her movements.
Neurological
Although the patient has a history of vertigo, she has since recovered from it and does not show any signs or symptoms alluding to its relapse.
Hematological
From the complete blood counts performed, the patient has high levels of white blood cells, especially the lymphocytes signifying an inflammation.
Psychosocial
No problem in this direction was witnessed.
References
Brandt, T. (2013). Vertigo: its multisensory syndromes. Springer Science & Business Media.
Lee, H. (2014). Isolated vascular vertigo. Journal of stroke, 16(3), 124.
Muhm, M., Danko, T., Winkler, H., & Ruffing, T. (2013). Assessment of prehospital injury severity in children: challenge for emergency physicians. Der Anaesthesist, 62(5), 380-388.
Siu, A. L. (2015). Screening for high blood pressure in adults: US Preventive Services Task Force recommendation statement. Annals of internal medicine, 163(10), 778-786.
