RUA Health History and Physical Assessment
Subjective Data
L.M. is a 45-year-old Cuban female born in Mexico and currently residing in California, United States of America. Spanish is her primary language, and English her second language. She stands 5 feet 6 inches tall and weighs 150 pounds. She is a married woman with no siblings. The reason for her visit is to address a recurring issue of abdominal pain and bloating that started about three months ago. L.M. states that the pain recurs after meals. She describes the pain as sharp, stabbing pain in the lower part of her abdomen. On a scale of 10, she rates the pain 10. On timing, she said after one two minutes after every meal. She has no significant medical history or surgical procedures and denies any known allergies to medications or substances. Her childhood vaccinations are current; she received the Covid-19 vaccine in January 2023. Her last flu shot was in October 2022. L.M. does not smoke, use illicit drugs, or consume alcohol. She defines health as feeling physically well and emotionally balanced. Immediate family history includes her maternal grandmother, who was diagnosed with type 2 diabetes at 60 and passed away at 75 due to complications related to diabetes. Her father was diagnosed with hypertension at age 45 and is managing it with Losartan 50 mg once daily. Her mother has a history of irritable bowel syndrome (IBS), diagnosed at age 38. Her mother takes over-the-counter simethicone as needed for bloating and gas.
L.M.’s review of systems on the skin and nails confirms the absence of itching. She states the absence of rashes on the skin. On the head and neck, L.M. confirms the absence of headaches and absence of neck injury or head injury. On the eye, she also confirms the absence of double vision and the absence of eyeglasses. On ears, she reported the absence of a hearing aid, the absence of ringing on ears, and the absence of impaired hearing. She states the absence of seasonal allergies absence of cough or shortness of breath, and absence of chronic bronchitis in the respiratory system. L.M. reported the presence of a change of diet, presence of abdominal pain, and presence of constipation in the gastrointestinal system. She also declares the absence of chest pain, palpitations, or swelling in the extremities. L.M. also confirms the absence of joint pain, stiffness, and absence of any history of fracture. She also states the absence of excessive thirst, urination, or intolerance to heat or cold. She also confirms the absence of pain or burning on urination, frequent urination, or incontinence. She also stated the presence of regular menstrual cycles that last on 30th July 2023 and the absence of genital discharge or pelvic pain. She stated the absence of bleeding disorders or anemia in the past.
Considerations
L.M. is currently at the generativity versus stagnation stage of Erikson’s Stages of Psychosocial Development, where she has to contribute to society and be part of the family. In this stage, individuals seek to form deep, meaningful relationships and long-term commitments with others (Orenstein & Lewis, 2022). L.M. expresses the importance of family and considers her loved ones as a source of emotional support. Culturally, L.M. values traditional healing practices and remedies. She mentions using herbal teas and home remedies passed down through generations to alleviate minor ailments. Understanding and respecting her cultural beliefs are essential in providing patient-centered care. L.M. has a robust support system consisting of her immediate family and close friends. They are crucial in providing emotional support and sharing cultural values and traditions.
Physical Examination: Objective Data
L.M.’s head is normocephalic and shows no indications of any unusual features. Her face is symmetrical and free of any noticeable imperfections. No suspicious lymph nodes or swelling are seen during a neck assessment. There is no sign of any visual impairment in L.M.’s eyes, which are equal, rounded, and light-responsive pupils present. There is no indication of squinting or any other unusual eye movements. No abnormalities or nasal discharge are visible, and the nose is dry. The mouth and throat of L.M. seem not to display any form of informalities; she is not having trouble swallowing. Upon inspection, no unusual lung sounds are heard. The cardiovascular system has no abnormal sounds or murmurs, which is average. There are no indications of blood swelling or varicose veins. No abnormalities were identified in the Neurological system after an examination. L. M. rates her abdominal pain on a scale of one to ten as 10. To identify what is causing this discomfort, more investigation is required. This examination turned up no other abnormalities. The musculoskeletal study also
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