NR601 Week 2 Discussion Part Two: Dyspnea Upon Excretion Soap Note.

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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. Other Medical Hx: Has not seen a dentist in over 15 years, the time she got her dentures Last colorectal screening was 11 years ago, Last mammogram was 5 years ago Has never had a DEXA/Bone Density Test, Last dilated eye exam was 4 years ago. Soc. Hx: She graduated from high school, and thought about college, but got married right away and then had kids a short time later. Her two sons and their wives live with her, take her to church and to the local senior center; they do all the cleaning, run errands, and do grocery shopping. Patient is a current tobacco user and has smoked 1 pack of cigarettes daily for the last 50 years and reports having no desire to quit. She uses occasional chew. She drinks one 4 ounce glass of red wine daily. Fam. Hx: Both parents are deceased. Father died of a heart attack; mother died of natural causes. She had one brother who died of a heart attack 20 years ago at the age of 52. CONSTITUTIONAL: No weight loss, fever, chills, (+) weakness, (+) fatigue. HEENT: Eyes: (+) visual loss, (+) decreased night vision, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations (+) BLLE edema. RESPIRATORY: (+) shortness of breath, cough or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: No Burning on urination. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history ofsplenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: No history of asthma, hives, eczema or rhinitis. Physical examination: Vital Signs Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP 110/70 T 98.0 po P 100 R 22, non-labored; Urinalysis: Protein 2+, Glucose: 4+ O: Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP 110/70 T 98.0 po P 100 R 22, non-labored; Urinalysis: Protein 2+, Glucose: 4+ HEENT: normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower dentures in place a fitting well. No tinnitus NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. Thyroid non-palpable LUNGS: Decreased breath sounds in bases bilaterally with rales, expiratory wheezing with prolonged expiratory phase noted throughout all lung fields. No costovertebral angle tenderness (CVAT) noted. Increase in AP diameter noted. HEART: Irregularly irregular rhythm; Unable to detect S3 or murmur ABDOMEN: Normal contour; active bowel sounds all four quadrants; no palpable masses. PV: Pulses are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally; [Show More]

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