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Running head: THE BIOGRAPHIC DATA 1

Patient Name: John Richard

Unit No.0123

Location: California

Informant: Young Male Patient

Chief Complaint: It is the first time the 56-year-old woman who has been having chest pain

until the last one week. He was born in 1961 in California, a black American, who has been

working as a security officer in the department of homeland security.

History of the present illness

About a week ago, the patient noticed an abrupt once over a period of about one minute

of intense chest pain. This was defined by the patient as a dull and dull aching in nature. The

chest began from the left para-sternal from which it then radiated to the neck. When this first

occurred, the patient was doing some work in her garden during the day, at around 2 pm. The

woman had worked for only half an hour when the pain started. After a rest under a shade for

about 20 minutes, the pain ended. The health record for the patient is drawn from the former

health records managed by the hospital at homeland security department, where has been

attending for all treatment since the time he started working for the DHS. He is married with 3

children.

Two more episodes of pain have been experienced since the first one within a span of one

week. Both of the two most recent episodes lasted for about 20 minutes and were also resolved

by taking a rest. No medical methosds have been employed to resolve the complication, apart

from taking a rest as denoted. Further, she has explained that there are no other symptoms

associated with the pains, however, she runs short of the breath when the pain sets in. the pain is

not related to physical movement, or food, the GERD sx or any palpable pain. No heart problems

have ever been reported by the woman, in fact, this is the first time she has experienced chest

THE BIOGRAPHIC DATA 2

pain. She also has never had any claudication. However, about 3 years ago, she was diagnosed

with HTN and hypertension. On the other hand, the woman does not smoke and has never had a

hormonal replacement therapy. Examination of the family history identifies one person with a

premature CAD, but the cholesterol level of the woman is not known so far.

Current Regimen

a) Chest X-ray

b) Upper limb training

c) Oxygen suplementation

d) Dietary maintenance

Medical History/Past History

1994; Abdominal hysterectomy and bilateral oophorectomy mainly for urine fibroids.

1995; she was diagnosed with the peptic ulcer, which ended after four months on cimetidine, but

there was no report related to cancer and lung disease.

1999; Bunionectomy

2000; she was diagnosed with hypertension, and the first medication for this is not known,

however, this complication stopped after five months.

Social History

Used to take about 2 to 3 bottles of alcohol on weekends, or a glass of wine after dinner.

Never used tobacco or any other illegal drug.

Family history; Her mother is aged 75 years at the moment and still going strong, while the dad

died of heart attack. There are no siblings. While in the family there is a positive trend of

hypertension, there is no record about diabetes or cancer.

THE BIOGRAPHIC DATA 3

Family Genogram

Systems Review

HEENT; Does not have headache complaint, vision, nose ear or the throat.

Gastrointestinal; The woman does not have any problem related to dysphagia, nausea, puking

or changes in the stool. However, she has epigastric pain which often occurs at night.

Genitourinary; The woman does not have any dysuria, polyuria, hematuria or vagina bleeding.

Musculoskeletal; she has lower back pain, which she experiences about once in every two

weeks after some engaging physical activities like working in the garden.

Neurological; The woman has no complains related to weakness, numbness or any form of in

coordination.

Physical Examination (Head-toe-Examination)

Vital signs; She has a blood pressure of 165/98, and a pulse rate of 90. The respiration is 20 and

temperatures are normal.

Husband

Died of

heart

attack

Wife now

aged 75

years

Richard

John-56

years

Wife to

John

50 years

Kid 1

Kid 2

Kid 3

THE BIOGRAPHIC DATA 4

Skin; Her skin is normal in appearance, texture as well as the temperature.

HEENT; The scalp is in normal condition. For example, the pupil is around 4mm and reactive to

light. The vessels denote normality and there is no haemorrhage. Further, the tympanic

membrane and the external auditory canals and nasal are also normal. The pharynx, the tongue

and the gums are all normal.

Neck; The neck moves easily without any resistance. No masses are eminent in the trachea and

the thyroid glands.

Chest; The lungs are operating well, however, there are crackles heard in the bases. There is also

some sound in the apex. The heart sound is absent. On the other hand, there are cystic changes

noted around the breast, without any nipple discharge.

Nodes; The cervical does not have any palpable nodes.

Abdomen; There is no distention in the abdomen, and it appears symmetrical. The sounds of the

bowel are normal and quality. Masses are also absent, and the liver span is 8 cm by percussion.

Externalities; The clubbing, cyanosis and edema are present. The rest is normal, such as the

peripheral pulse, femoral and dorsalis pedis.

Genital/rectal; The sphincter tone of the rectal is normal, and the rectal masses not present. The

stool is brown in color.

Accident: Never had an accident

Childhood ilness: Chicken pox

Health Promotion

The woman has chest pain related to substernal chest pain which suggests ischemic

cardiac basis. The earlier diagnosis of hypertension expresses her risk of cardiovascular attack in

future or some coronary artery diseases. The most likely diagnosis for this patient is angina

THE BIOGRAPHIC DATA 5

pectoris. Some other possible outcomes that are however not likely, include GERD which is

most likely to occur at night. Also, peptic ulcer disease is likely to come about as results of some

predisposing factors like nausea, vomiting and the abdominal pain. While the presence of

dyspnea may suggest the pulmonary components, the absence of fever, and cough lowers the

possibility.

Perception of the Illness

A. Cardiovascular conditions/complications

B. Cholesterol

C. Penicillin allergy

D. Fibrocystic disease of the breast

E. Dyspnea

Plan

I. The chest pain of the patient should be monitored very closely as this may pre-empt

myocardial infarction.

II. Aspirin should be used to reduce the patient exposure to myocardial

III. Diuretics for dyspnea should be initiated to help treat her BP.

IV. The Lab works should comprise of activities such as BUN baseline EKG and electrolyte.

THE BIOGRAPHIC DATA 6

Reference

Jarvis, C. (2015). Physical examination and health assessment. Elsevier Health Sciences.

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