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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.


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 finds no fractures or joint deformities. Her arms and legs move freely as usual. Her muscles are rated as having a full range of strength and function (5 out of 5).

Needs Assessment

Education is the best way of creating awareness about a specific disease that needs prevention and cure. For L.M. to address her recurring abdominal pain and bloating, their two identified education needs based on the history and physical examination. Firstly, L. M needs education on dietary modification and stress management techniques to address the recurring abdominal pains. These signs are related to Irritable Bowel Syndrome (IBS). It is a disorder that affects the gastrointestinal tract and is characterized by bloating, abdominal pain, and weird bowel habits. According to recent research, IBS can be managed by avoiding trigger foods and increasing fiber intake (Algera et al., 2019). Employing stress management techniques such as mindfulness meditation or deep breathing exercises reduces the impact of stress on her digestive system.

The second education need that can help manage gastrointestinal tract effects such as abdominal pain or bloating is the importance of regular exercise and maintaining a healthy weight to prevent future health issues. Considering that her family history had diabetes and hypertension, regular physical activities will greatly benefit her, such as weight management, improved cardiovascular health, and reduced risk of chronic conditions like type 2 diabetes and hypertension (Łuniewski et al.; 2023). L.M. can reduce the risk of developing these conditions and improve her well-being by adopting a physically active lifestyle. However, her psychosocial and cultural considerations may influence the needs assessment. Her generativity versus stagnation stage may affect her willingness and capacity to learn new things. Her cultural beliefs may also act as barriers to putting the medical advice provided into practice. L.M. has a high chance of being supported by her solid circle of family and friends throughout the proposed teaching process. Their emotional support and shared cultural values may positively impact her adherence to the suggested dietary changes, stress-reduction methods, and exercise regimens.


I made a welcoming and culturally sensitive environment for L.M. during our interaction in a private exam room every morning. My strategy of using open-ended questions and active listening aided in effective communication. The interview went well, and L.M. was cooperative and gave thorough information. An interpreter was utilized to navigate through the language barrier. In order to effectively tailor health education, I learned to consider particular cultural factors and gather more specific information in subsequent interactions. Next time, I will ask more probing questions about L.M.’s dietary preferences, meal patterns, and sources of stress to design a more personalized and effective intervention. Overall, the experience highlighted the significance of providing patient-centered care, respecting each person’s beliefs and values, and enhancing healthcare delivery through developing communication skills and cultural competency.


Algera, J., Colomier, E., & Simrén, M. (2019). The dietary management of patients with irritable bowel syndrome: a narrative review of the existing and emerging evidence. Nutrients11(9), 2162.

Łuniewski, M., Matyjaszek-Matuszek, B., & Lenart-Lipińska, M. (2023). Diagnosis and Non-Invasive Treatment of Obesity in Adults with Type 2 Diabetes Mellitus: A Review of Guidelines. Journal of Clinical Medicine12(13), 4431.

Orenstein, G. A., & Lewis, L. (2022). Erikson stages of psychosocial development. In StatPearls [Internet]. StatPearls Publishing. Erikson stages of psychosocial development. In StatPearls [Internet]. StatPearls Publishing.


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