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Examination and history of each client's health

Miriam Walker was admitted to California Pacific Medical Center (CPMC) on July 1, 2006, with chest pains that bothered her for five days.
Background Information on the Present Illness: Miriam Walker, a 45-year-old woman, had never suffered from chest pains before, and this was her first visit to the hospital. She stated that she was in good health until five days before her admission when she started having chest pains that lasted several minutes. Her pain began in her left parasternal region and spread to her neck, she said. Miriam first felt the pain five days ago, around noon, when she was weeding. her garden. According to her story, she first felt fatigue before the onset of the pain after working for 45 minutes. Her chest pains were followed by shortness of breath, but she did not experience vomiting, nausea or sweating common symptoms (Glinz, 2012). After she rested in a cool area, the pain was resolved in approximately five to ten minutes.
Before her admission, Miriam experienced two additional episodes of pain that followed a similar pattern as during the first episode. Other than rest, Miriam did not undergo any other intervention to relieve her pain. In her description, the most apparent symptom was shortness of breath, but no other accompanying symptoms of palpitations, exertional orthopnea or dizziness were reported (Mitra, 2007). Moreover, her pain was not associated with food or movement.
Previously, Miriam had no records of heart problems, claudication, chest pains and diabetes. However, she was diagnosed with hypertension (HTN) three years ago. On further examination, Miriam revealed a family history of premature CAD, but she was not under any hormone replacement therapy. Besides, she was not aware of her cholesterol level.
Assessment
The description of the patient’s aching, dull and exertion brought about by substernal chest pain reveals that the pain originates from Ischemic cardiac. Since the patient was diagnosed with early surgical menopause and hypertension, she will certainly develop coronary artery disease with this pertinent condition. These multiple risk factors alongside the patient’s presentation make it possible to suggest angina pectoris as the most appropriate diagnosis. Besides, the occurrence of increasing pain during the rest also highlights the presence of unstable angina. Thus, the adequate hospitalization with proper medication is required.
Recommendation
1. The patient should be treated with platelet inhibitors to lower the risk of developing myocardial infarction. To reduce the occurrence of pain symptoms, the patient should be treated with nitrates. In case she fails to respond immediately to this medication, morphine analgesia should be administered.
2. The patient should be monitored carefully to access any prolonged chain pain that is suggestive of impending myocardial infarction. Since the patient experienced prolonged chest pain, she should be admitted to the telemetry floor for further examination and treatment.
3. The cholesterol level of the patient should be accessed and monitored carefully, and, upon her discharge, she should be advised of the best weight loss and exercise program. If her level of cholesterol is high, cholesterol-lowering medication should be prescribed.

References
Glinz, W. (2012). Chest trauma: Diagnosis and management: Springer.
Mitra, P. K. (2007). Handbook of practical chest physiotherapy. New Delhi: Jaypee Bros.
Medical Publishers.

September 21, 2021

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