What additional history and physical information should you obtain related to her admitting diagnosis? Name at least four for each

Question

Please help and be physical examination and patient history specific.

R.K. is an 85-year-old woman who lives with her husband, who is 87. Two nights before her admission to
your cardiac unit, she awoke with heavy substernal pressure accompanied by epigastric distress. The pain
was reduced somewhat when she rolled onto her side but did not completely subside for about 6 hours.
The next night, she experienced the same chest pressure. The following morning, R.K.'s husband took her
to the physician and she was subsequently hospitalized to rule out myocardial infarction (MI). Laboratory
specimens were drawn in the emergency department. She was given an intravenous (IV) line, oxygen (O2)
at 2 L via nasal cannula, and 325 mg chewable, non–enteric-coated aspirin.
You obtain the following information from your history and physical examination: R.K. has no history
of smoking or alcohol use, and she has been in good general health, with the exception of osteoarthritis
of her hands and knees and some osteoarthritis of the spine. Her only medications are simvastatin
(Zocor), ibuprofen as needed for bone and joint pain, and "herbs." Her admission vital signs (VS) are blood
pressure 132/84 mm Hg, pulse 88 beats/min, respirations 18 breaths/min, and oral temperature 99 ° F
(37.2 ° C). Her weight is 114 lb and height is 5 ft, 4 in. Moderate edema of both ankles is present; capillary
refill is brisk and peripheral pulses are 1+. You hear a soft systolic murmur. She denies any discomfort at
present. You place her on telemetry, which shows the rhythm in the following figure.

Answer 1

History
• Medication allergies.
• Pain, fatigue, or dyspnea (if present) and whether there have been recent changes in any of
them: Assess intensity, characteristics, onset, location, duration, what makes it better or worse,
associated symptoms, and possible radiation of pain.
• Herbal products: Try to identify exactly what herbs she takes, the implications for interaction with
her current medications, and her complaints.
• General activity level: Especially focus on changes in housework or increased fatigue or symptoms
during housework in women.
• Sleep patterns.
• General perceived stress level and coping mechanisms.
• Accustomed diet.
• What type of help that she and her husband need at home to stay independent.

Physical Examination

• Cardiac sounds: Listen for S1 and S2 and for additional sounds such as S3, S4, valvular click, or rub.
Listen to the heart murmur, and identify quality and intensity and whether the extra sound occurs
during systole or diastole.
• Jugular venous distention (JVD): This is an indication of elevated right atrial pressure, which can be
elevated in severe heart failure (HF) and fluid overload.
• Lungs: Assess for signs and symptoms of HF. Early-stage HF cough is a persistent, dry hack; endstage
HF features crackles, dyspnea, and cough productive of frothy sputum.
• Mental status: Assess for orientation, alertness, anxiety, confusion, and restlessness.