Cardiovascular Assessment Module 5

PERSONAL PROFILE

Patient’s Name: E.A.M

Age: 29
Date of Birth: 1991 Aug 17
Gender: Female
Religion: Roman Catholic
Ethnic Background: Asian (Filipino)

PRESENT HEALTH STATUS

Patient EAM started feeling chest pains 2 days ago, sometimes with difficulty
breathing. Patient verbalized that she would also feel the pain when she coughs and
it would radiate to her left shoulder. Patient said that the pain does not last long, and
is intermittent. Only aggravated when the patient coughs. No known chronic
illnesses. Patient is currently taking Vortioxetine 10mg QHS. No known side effects
from the medication and the patient is taking them as prescribed.

PAST HEALTH HISTORY

Patient EAM was diagnosed with arrhythmia last 2017. Was on bed rest for 7
days. No prescribed medication. Patient had regular blood pressure, ranging from
120/80-110/80 mmHg. No known congenital heart disease or defect. No growing
pains, Patient EAM verbalized that she never had heart surgery. An EKG Test was
done last 2017 revealing that patient EAM had arrhythmia. No treatment was done
but the patient was on bed rest and constant monitoring for 7 days.

MEDICATION HISTORY

Patient EAM was not prescribed any cardiovascular medications. Patient is

currently taking Vortioxetine 10mg QHS.

FAMILY HISTORY

Paternal grandparents were known to have heart disease and cancer.

Maternal Grandparents were known to be diabetic and hypertensive. Father of the
patient was known to have a heart disease, and the mother is known to be diabetic.
Patient’s mother is currently taking Metformin 500mg PO BID.

SOCIO-ECONOMIC HISTORY

Patient EAM is a 29 year old female, single and belongs to a middle class
family. Patient owns her business as well as plays a role in managing their family
business. Known businesses are in food, transportation, construction, and in
healthcare. Patient was known to be an occasional drinker and occasional smoker,
smoking 8 sticks at the most per day. Patient tried quitting for 3 years. Patient has
never used any illegal drugs. Patient rarely exercises, and is known to patronize
caffeinated drinks.
Cardiovascular Assessment Module 5

PHYSICAL ASSESSMENT

A. VITAL SIGNS

Temperature: 36.7 C
BP: 120/80 mmHg
RR: 18 cpm
PR: 68 bpm
O2 Saturation: 98%

B. FINDINGS

Patient sitting in a semi-fowler’s position, with regular respirations;

jugular pulsations visible without distention; extremities symmetric in size; skin
intact with elastic turgor, warm with color appropriate for patient without pallor
or redness; pulses regular rhythm; capillary refill <2 seconds in all extremities;
nail beds pink with an angle of 160 degrees. Hair distribution even on upper
and lower legs. Chest rounded and symmetric. PMI at 5th ICS, MCL, S1,
louder at the apex, and S2, louder at the base, regular rate and rhythm
without murmurs.
Cardiovascular Assessment Module 5

PERSONAL PROFILE

Patient’s Name: FLDT

Age: 18
Date of Birth: October 13, 2002
Gender: F
Religion: Christian
Ethnic Background: Asian (Filipino)

PRESENT HEALTH STATUS

Patient FLDT has no record of any chronic illnesses. Patient is currently

taking supplements, such as AD-C Plus (15mg capsule) and ImmunPro (10mg
tablet), which are both taken PO QD, to help boost immune function. Patient further
reports that there were no adverse effects in the course of taking these medications.

PAST HEALTH HISTORY

Patient FLDT has never been diagnosed with a cardiac condition. The
patient’s blood pressure normally ranges from 110/70-120/80 mmHg and was not
prescribed any medication to either decrease or increase blood pressure. The
patient stated that she has never had congenital heart disease or any heart defects
and did not experience any growing pains. The patient has not had any surgical
procedures done to her heart and had a chest x-ray last February 22, 2020. Results
showed normal cardiopulmonary findings, such as clear lung fields, unenlarged
cardiac shadow, and intact diaphragm and costophrenic recesses.

MEDICATION HISTORY

Patient FLDT expressed that she never had to take any medications for
cardiac conditions. Medications taken at present are AD-C Plus (15mg capsule) and
ImmunPro (10mg tablet), which are both taken PO QD, to increase her resistance to
colds and infection and boost her immune function.

FAMILY HISTORY

The patient’s grandfather is diabetic, hypertensive, and suffers from arthritis.

Patient mentioned that her grandfather started having these illnesses around his
mid-50s and was prescribed with medications, such us Glucophage XR (500mg
tablet), Urinorm (80mg tablet), and Amvasc BE (10mg tablet), which are all taken PO
QD. The prescribed medications helped normalize the blood sugar levels, uric acid,
and blood pressure of the said relative.
Cardiovascular Assessment Module 5

SOCIO-ECONOMIC HISTORY

Patient FLDT’s current civil status is single and also belongs to a middle class
family. The patient is currently a first-year full-time college student taking up a
Bachelor of Science in Nursing. Patient lives with her parents, three siblings, and
maternal grandparents. The patient’s father and mother own and manage their
family’s construction company and hardware shop. the patient has never had a habit
of alcohol consumption, smoking or chewing tobacco, as well as using any illicit
drugs.

PHYSICAL ASSESSMENT

A) Vital Signs

Temperature: 36.9 C
BP: 110/70 mmHg
RR: 18 cpm
PR: 81 bpm
O2 Saturation: 98%

B) Findings

Patient sitting in a relaxed position, with regular respirations; jugular

pulsations visible without distention; extremities symmetric in size; skin intact
with elastic turgor, warm with color appropriate for patient without pallor or
redness; pulses regular rhythm; capillary refill <2 seconds in all extremities;
nail beds pink with an angle of 160 degrees. Hair distribution even on upper
and lower legs. Chest rounded and symmetric. PMI at 5th ICS, MCL, S1,
louder at the apex, and S2, louder at the base, regular rate and rhythm
without murmurs.