High School

Present Problem:
Maria Almazon is a 68-year-old woman who presents to the emergency department after experiencing three days of progressive weakness. She denies chest pain but admits to shortness of breath that increases with activity. She also reports epigastric pain with nausea, which has been intermittent for 20-30 minutes over the last three days. Her epigastric pain has worsened and is now radiating into her neck. Her husband called 9-1-1, and she was transported to the hospital by emergency medical services (EMS).

Personal/Social History:
JoAnn is a recently retired math teacher who continues to substitute teach part-time. She is physically active and lives independently with her spouse in her own home. She has smoked 1 pack per day for the past 40 years. JoAnn appears anxious and immediately asks repeatedly for her husband upon arrival.

Question:
What data from the histories are relevant and have clinical significance to the nurse?

Relevant Data from Present Problem:
- Progressive weakness for 3 days
- Denies chest pain
- Reports shortness of breath, worsens with activity
- Intermittent and worsening epigastric pain with nausea for 3 days, radiating into neck
- Classic signs and symptoms of angina

Relevant Data from Social History:
- Physically active
- Lives with husband, independently
- 1 pack per day smoker for 40 years
- Anxious
- Indicative of Coronary Artery Disease

Answer :

Final answer:

The patient's history of progressive weakness, shortness of breath with activity, and radiating epigastric pain suggest classic symptoms of angina which combined with her lifestyle habits like smoking, could point towards Coronary Artery Disease.

Explanation:

The relevant data from the patient's present problem and social history is critical to inform a nurse's assessment. In the present problem, the note of progressive weakness for 3 days, increase in shortness of breath with activity, intermittent and worsening epigastric pain with nausea and its radiation into the neck for 3 days, points to classic symptoms of angina. In regard to the social history, the patient is retired but physically active, living independently with the spouse, a smoker with a 40-year history, and presents an anxious appearance upon arrival. The latter data is significant as it can be indicative of Coronary Artery Disease(CAD).

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It's important for the nurse to consider these relevant data points and clinical significance while assessing Maria's condition, as they can help guide further evaluation and treatment decisions.

In this case, there are several relevant data points from the patient's history that have clinical significance for the nurse. Let's break them down:
1. Progressive weakness for three days: This symptom indicates that Maria's condition is worsening over time. It suggests that there might be an underlying medical issue that needs to be addressed promptly.

2. Shortness of breath (SOB) worsening with activity: This symptom, along with the progressive weakness, could be indicative of a cardiovascular problem. It suggests that Maria's heart might not be pumping efficiently, causing a decrease in oxygen supply to her body.

3. Intermittent and worsening epigastric pain with nausea: This symptom, lasting for three days, is concerning as it could be a sign of a serious condition. The fact that the pain is radiating into her neck raises further suspicion.

4. Physically active and living independently: These aspects of Maria's social history indicate that she generally leads an active lifestyle and is capable of managing her daily activities. However, it's important to note that even physically active individuals can still experience health issues.

5. Smoking history of 1 pack per day for 40 years: Smoking is a significant risk factor for various health problems, including cardiovascular diseases. In this case, it increases the likelihood of Maria experiencing a heart-related issue.

6. Anxious behavior: Maria's anxiety upon arrival could be a result of her current physical distress. However, it's crucial for the nurse to consider whether the anxiety is a symptom of an underlying condition or a separate issue that needs attention.

Putting it all together, the relevant data from Maria's history point to the clinical significance of her symptoms being potentially related to coronary artery disease. The symptoms of progressive weakness, shortness of breath worsening with activity, epigastric pain with nausea radiating into the neck, and the smoking history all align with classic signs and symptoms of angina, which is often associated with coronary artery disease.

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