NR 601 Week 2 Part 1

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Patient Information: Initials: B.J. Age: age 70 year old Sex: Female Race: Caucasian Insurance: unknown CC: Generalized fatigue HPI: Onset: 1 year (after the dead of her husband) Location: ge... neralized Duration: 1 year to present Characteristics: fatigue, short of breath, and insomnia Aggravating Factors: Dyspnea upon exertion, her feet burns and tingling, coughing, swollen feet, and cannot see well especially at night Relieving Factors: none reported Treatment: none reported Current Medications: 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 Allergies: Amoxicillin Immunization: She receives an annual flu shot. Last flu shot was this year Has never had a Pneumovax Has not had a Td in over 20 years Has not had the herpes zoster vaccine Other: 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 Labs from last year’s visit: Hgb. 12.2, Hct. 37%, Hgb. A1C 8.2%, K+ 4.2, Na+140, Cholesterol 186, Triglycerides 188, HDL 37, LDL 98, TSH 3.7, ALT/AST WNL. PMH: Chronic back pain Hypertension Previous history of MI in 2010 Surgery Hx: 2010-Left Anterior Descending (LAD) cardiac stent placement 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. 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 questions: In the last 3 months have you experienced any of the following: fever, chills, night sweats, unexplained changes in appetite, weight gain, weight loss, or weakness? Differential Diagnoses with rationale 1. Diabetics Peripheral Neuropathy (ICD 9-250.60), diabetic patients often have tingling and burning in their feet. This is one of the symptoms of uncontrolled diabetes which leads to peripheral neuropathy (Dunphy, 2011). 2. Congestive Heart Failure (ICD 9-428.0), According to Heart Association (2012), shortness of breath, persistent coughing, fatigue, lack of appetite or nausea, and impaired thinking. These are classic signs and symptoms of heart failure. 3. Depression (ICD 9-296.22), presents with sign and symptoms of fatigue, lack of energy, insomnia, lack of movitional to perform ADLs, and lack of everyday interest in activity that was once enjoyable (Kupfer, Frank, & Phillips, 2012). 4. Diabetics with Ophthalmic manifestations (ICD 9-250.5), Pt states she cannot see well especially at night. 5. Paroxysmal nocturnal dyspnea (ICD 9-786.09), PT states that’s she awakens short of breath through the night & the use of 3 pillows while sleeping (Dunphy, 2011). Questions based on ROS: [Show More]

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