History and Interview- Healthy 25 years Old Female

History and Interview- Healthy 25 Years Old Female

Date of History/Interview: 14/4/2022

Source of history and Reliability: Self-reported medical history provided by the volunteer patient.

Biographical Data

Name: SZ

Primary language: English

Age and Date of Birth: 25 years old, born 01/16/1998

Place of Birth: United States

Gender: Female

Race: Caucasian

Marital Status: Single

Ethnic/Cultural Origin: Caucasian

Education: Bachelor’s degree

Occupation/Professional: Nurse

Health insurance: Commercial Insurance

Chief Complaint (reason for seeking health care)

“I have been experiencing chest pain for the past two hours that radiates to my left shoulder and arm.”

History of Present Illness

Sandrine Zang is a 25-year-old female presenting with chest pain radiating to the left shoulder and arm for the last two hours. She does not have any respiratory difficulty or abnormalities of the shape or movement of the chest. She does not have any chest expansion, and there is no tactile fremitus posteriorly. She does not have any diaphragmatic excursion, and posterior breath sounds are heard without any egophony, bronchophony, or pectoriloquy. Upon inspection, the anterior chest is normal, with no abnormalities in size, shape, or bruising. There is no tactile fremitus anteriorly, and percussing the anterior chest does not reveal any abnormalities. Anterior breath sounds are heard normally. Hire our assignment writing services if your assignment is devastating you.

Past Medical History

Medical Hx: No major illnesses, injuries, hospitalizations, transfusions, or disabilities

Childhood Illnesses: Measles, mumps, rubella, chickenpox

Surgical Hx: None

Obstetric Hx: No pregnancies, term deliveries, preterm births, abortions (spontaneous or induced), number of children living

Immunizations: Up to date

Psychiatric Hx: No childhood or adult (treated or hx of)

Allergies: No known allergies

Current Medications: None

Last Examination Date: Physical exam two months ago

Family History

Father: Living; Healthy

Mother: Living; Healthy

Grandparents: Both living, Healthy

Spouse: None

Children: None

Life Style Patterns

Immigrant status: Native

Spiritual resources/religion: Protestant

Health perception: Good

Nutritional patterns: Appetite is good; Satisfied with current weight; No gains or losses; Usual intake is balanced; No cultural restrictions/intolerances; Takes in 6-8 glasses of fluid per day

Elimination patterns: Bowel is regular; Bladder is regular; No incontinence

Living environment: City; Urban; Private residence

Occupational health: No known exposure to environmental toxins at work

Functional assessment: ADLs are met; IADLs are met; Positive interpersonal relationships/resources

Role and family relationships: Immediate family consists of mother and father; Family decisions are made collaboratively; No impact of family member’s health on family

Cognitive function: Memory is good; Speech is clear; Judgment is good; Senses are normal

Rest/sleep patterns: Sleeps 7-8 hours per night; No naps; Uses one pillow; No aids for sleep

Exercise patterns: Walks for 30 minutes 3-4 times per week

Hobbies/recreation: Listening to music, reading, cooking, painting; No travel outside of the US

Social habits: Does not use tobacco, alcohol, or other drugs/substances

Intimate partner violence: No

Coping/stress management: No major life changes in past 2 years; Does not feel tense; Copes with stress through listening to music, reading, and painting

Sexual patterns: Not sexually active; No gender preference; No changes to sexual health/function

III. Review of Symptoms

	Symptoms to Inquire About (please see page 54–56 in Jarvis textbook)	Document pertinent negatives and/or positives The first system is addressed to provide a guide
General	Wgt Δ; weakness; fatigue; fevers	Pertinent negatives: No weight loss; no weaknesses, fatigue, or fevers Pertinent positives: Positive weight gain over past 2 months
Skin	Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails	Pertinent negatives: Negative for any rashes, lumps, sores, itching, dryness, color change, or changes in hair/nails Pertinent positives: None
Head	Headache; head injury; dizziness or vertigo	Pertinent negatives: Negative for headaches, head injury, dizziness, or vertigo Pertinent positives: None
Eyes	Vision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotoma	Pertinent negatives: Negative for vision changes, eye pain, redness or swelling, corrective lens use, excessive tearing, double vision, blurred vision, scotoma Pertinent positives: Positive for the last eye exam
Ears	Hearing Δ; tinnitus; earaches; infections; discharge, hearing loss, hearing aid use	Pertinent negatives: Negative for hearing changes, tinnitus, earaches, infections, discharge, hearing loss, or hearing aid use Pertinent positives: None
Nose/ Sinuses	Colds; congestion; nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds; change in sense of smell; sinus pain	Pertinent negatives: Negative for colds, congestion, nasal obstruction, discharge, itching, hay fever or allergies, nosebleeds, changes in the sense of smell, or sinus pain Pertinent positives: None
Throat/ Mouth	Bleeding gums; mouth pain, toothache, lesions in mouth or tongue, dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered taste	Pertinent negatives: Negative for bleeding gums, mouth pain, toothache, lesions in mouth or tongue, dentures, sore tongue, dry mouth, sore throats, hoarseness, tonsillectomy, or altered taste Pertinent positives: Positive for the last dental exam
Neck	Lumps; enlarged or tender nodes, swollen glands; goitre; pain; neck stiffness; limitation of motion	Pertinent negatives: Negative for lumps, enlarged or tender nodes, swollen glands, goitre, pain, neck stiffness, or limitation of motion Pertinent positives: None
Breasts	Lumps; pain; discomfort; nipple discharge, rash, surgeries, history of breast disease; perform self-breast exams and how often, last mammogram; any tenderness, lumps, swelling, or rash of axilla area.	Pertinent negatives: Negative for lumps, pain, discomfort, nipple discharge, rash, surgeries, history of breast disease, tenderness, lumps, swelling, or rash of the axilla area Pertinent positives: Positive for self-breast exams every month; Last mammogram 2 years ago
Pulmonary	Cough — productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin or pollution exposure; last Chest x-ray, TB skin test	Pertinent negatives: Negative for cough, hemoptysis, dyspnea, wheezing, pleuritic pains, H/O lung disease, toxin or pollution exposure, or TB skin test Pertinent positives: Positive for last chest x-ray
Cardiac	Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia, or CAD	Pertinent negatives: Negative for chest pain or discomfort, palpitations, dyspnea, orthopnea, edema, cyanosis, nocturia, H/O murmurs, hypertension, anaemia, or CAD Pertinent positives: None
G/I	Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance	Pertinent negatives: Negative for appetite changes, jaundice, nausea/emesis, dysphagia, heartburn, pain, belching/flatulence, changes in bowel habits, hematochezia, melena, haemorrhoids, constipation, diarrhoea, or food intolerance Pertinent positives: None
GU	Frequency; nocturia; urgency; dysuria; hematuria; incontinence Females: Use of kegal exercises after childbirth; use of birth control methods; HIV exposure; Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP; vaginal discharge; itching; sores; lumps; menopause; hot flashes; post-menopausal bleeding; Males: Caliber of urinary stream; hesitancy; dribbling; hernia, sexual habits, interest, function, satisfaction; discharge from or sores on penis; HIV exposure; testicular pain/masses; testicular exam and how often	Pertinent negatives: Negative for frequency, nocturia, urgency, dysuria, hematuria, incontinence, kegel exercises, birth control methods, HIV exposure, menarche, frequency/duration of menses, dysmenorrhea, PMS symptoms, bleeding between menses or after intercourse, LMP, vaginal discharge, itching, sores, lumps, menopause, hot flashes, post-menopausal bleeding, the calibre of urinary stream, hesitancy, dribbling, hernia, sexual habits, interest, function, satisfaction, discharge from or sores on the penis, HIV exposure, testicular pain/masses, or testicular exam Pertinent positives: None
Peripheral Vascular	Claudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots, discoloration of hands, ulcers	Pertinent negatives: Negative for claudication, coldness, tingling, numbness, leg cramps, varicose veins, H/O blood clots, discolouration of hands, or ulcers Pertinent positives: None
Musculoskeletal	Muscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk disease	Pertinent negatives: Negative for muscle or joint pain or cramps, joint stiffness, H/O arthritis or gout, limitation of movement, or H/O disk disease Pertinent positives: None
Neuro	Syncope; seizures; weakness; paralysis; stroke, numbness/tingling; tremors or tics; involuntary movements; coordination problems; memory disorder or mood change; H/O mental disorders or hallucinations	Pertinent negatives: Negative for syncope, seizures, weakness, paralysis, stroke, numbness/tingling, tremors or tics, involuntary movements, coordination problems, memory disorder or mood change, H/O mental disorders, or hallucinations Pertinent positives: None
Heme	Hx of anaemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation	Pertinent negatives: Negative for hx of anaemia, easy bruising or bleeding, blood transfusions or reactions, lymph node swelling, or exposure to toxic agents or radiation Pertinent positives: None
Endo	Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size; H/O diabetes, thyroid disease; hormone replacement; abnormal hair distribution	Pertinent negatives: Negative for heat or cold intolerance, excessive sweating, polydipsia, polyphagia, H/O diabetes, thyroid disease, hormone replacement, or abnormal hair distribution Pertinent positives: Positive for polyuria
Psych	Nervousness/anxiety; depression; memory changes; suicide attempts; H/O mental illnesses	Pertinent negatives: Negative for nervousness/anxiety, depression, suicide attempts, or H/O mental illnesses Pertinent positives: Positive for progressive memory changes

Objective:

To assess Sandrine Zang’s medical history and lifestyle patterns

To review pertinent positives and negatives for each symptom inquired about

Assessment:

The patient is a 25-year-old female presenting with chest pain that has radiated to the left shoulder and arm for the past two hours. The patient does not have any respiratory difficulty or abnormalities in the thoracic region. Physical examination is negative for any cardiac, gastrointestinal, genitourinary, peripheral vascular, musculoskeletal, neurological, haematological, endocrine, or psychological abnormalities. The most likely diagnosis is non-cardiac chest pain (Campbell et al., 2017; Lakshmanadoss, 2020).

Differential diagnoses include:

Muscular chest wall pain

Gastrointestinal-related chest pain

Anxiety-related chest pain

Plan:

Order laboratory tests, such as a complete blood count, comprehensive metabolic panel, and cardiac enzyme panel, to rule out any cardiac causes of chest pain (Campbell et al., 2017; Lakshmanadoss, 2020).

Perform a chest x-ray to evaluate for any pulmonary causes of chest pain.

Refer the patient to a gastroenterologist for further evaluation and possible endoscopy to rule out any gastrointestinal causes of chest pain.

Refer the patient to a mental health specialist for further evaluation and possible psychotherapy and/or medication management to rule out any anxiety-related causes of chest pain.

Educate the patient about chest pain, including causes and treatment options.

Instruct the patient to return if symptoms worsen or do not improve.

References

Campbell, K. A., Madva, E. N., Villegas, A. C., Beale, E. E., Beach, S. R., Wasfy, J. H., Albanese, A. M., & Huffman, J. C. (2017). Non-cardiac Chest Pain: A Review for the Consultation-Liaison Psychiatrist. Psychosomatics, 58(3), 252–265. https://doi.org/10.1016/j.psym.2016.12.003

Lakshmanadoss, U. (2020). Differential Diagnosis of Chest Pain. In Google Books. BoD – Books on Demand. https://www.google.com/books/edition/Differential_Diagnosis_of_Chest_Pain/jKf8DwAAQBAJ?hl=en&gbpv=1&dq=Differential+diagnoses+include:+1.+muscular+chest+wall+painFree Essay Sample

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The purpose of this assignment is to practice the skills you have learned and demonstrate your ability to assess the thorax, lungs, and cardiovascular system.

Assume the patient is a healthy 25-year-old female. Name: Sandrine Zang. DOB 01/161998.

Below are the required pieces in your assessment.

Thorax:

Assess the patients for any signs of respiratory difficulty.
Inspect the shape and movement of the chest.
Assess for chest expansion.
Palpate for tactile fremitus posteriorly.
Percuss the posterior chest.
Percuss for diaphragmatic excursion.
Auscultate posterior breath sounds.
Auscultate for egophony, bronchophony, and pectoriloquy.
Examine the anterior chest.
Observe for any abnormalities (size, shape, bruising).
Auscultate for tactile fremitus anteriorly.
Percuss the anterior chest.
Auscultate anterior breath sounds.

CV:

Assess JVP.
Assess carotid pulses.
Assess the brachial artery.
Inspect and locate the PMI.
Palpate for thrills/bruits.
Auscultate heart sounds.

Next, you will need to document your findings.