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NR601 Week 2.Soap

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Discussion Part Two: with Dyspnea upon exertion. S. CC: “ Here for my check up” HPI: B.J. is a 70 year old Caucasian Female, who presents with multiple complains: burning and tingling in feet... , Dyspnea upon exertion SOB requiring 3 pillows to sleep at night, dyspnea with walking to bathroom, coughing that disrupts sleep, tiredness, swollen feel, vision problems, heart pains, loss of interest in doing anything since husband died. Onset: most likely over1 year ago Location: generalized, Feet, chest, lungs, eyes Duration: Ongoing, 1 year Characteristics: fatigue, short of breath, and insomnia Aggravating Factors: Generalized fatigue, burning and tingling to feet, coughing, swollen feet, and cannot see well especially at night Relieving Factors: none reported Treatment: none reported Current medication Coreg 6.25 mg PO BID Colace 100 mg PO BID Glucotrol XL 10 mg PO daily Lantus insulin 20 units at HS K-dur 20 mEq PO QD Furosemide 40 mg PO QD L-Thyroxine 112 mcg PO QD Allergy to Amoxicillin PMHx: Chronic back pain Hypertension Previous history of MI in 2010 B.J’s Immunization Hx are: B.J admits to receiving annual flu shot and is current. However, she has never recieved Pneumovax , no Td vaccination in over 20 years, no herpes zoster vaccine. [Show More]

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