NR 601 Week 2 ACC/AHA Guidelines Discussion Graded A / Week 2: ACC/AHA Guidelines Discussion
Please review the following case.
Chief complaint: medication refill " medicine"ran out of
HPI: BJ, a 68-year-old AA fe
...
NR 601 Week 2 ACC/AHA Guidelines Discussion Graded A / Week 2: ACC/AHA Guidelines Discussion
Please review the following case.
Chief complaint: medication refill " medicine"ran out of
HPI: BJ, a 68-year-old AA female presents to the clinic for prescription refills. The patient also indicates that she has noticed shortness of breath which started about 3 months ago. The SOB gets worse with activity, especially when she is playing with her grandchildren but it goes away once she sits down to rest. She reports that she is also bothered by shortness of breath that wakes her up at night, but it resolves after sitting upright on 3 pillows. She also has lower leg edema which started 1 week ago. She also indicates that she often feels light headed and faint while going up the stairs, but it subsides after sitting down to rest. She has not tried any OTC medications at home. She never filled her prescriptions, which she received at her checkup 6 months ago, she did not think it was important.
PMH:
Hypertension
Previous history of MI in 2010 Surgeries:
2010-Left Anterior Descending (LAD) cardiac stent placement
Allergies : Amoxicillin Vaccination History:
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 Social history:
High school graduate, a widow with one son who loves out of state. She drinks one 4-ounce glass of red wine daily. She is a former smoker that stopped 20 years ago.
Family history:
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.
ROS:
Constitutional: Lightheaded and faint with exertion.
Respiratory: Shortness of breath with exertion (playing with grandchildren and stairs). + Orthopnea
Cardiovascular: + leg and ankle swelling x 1 week
Psychiatric: Not taking medications for 6 months - "ran out" Physical examination:
Vital Signs
Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP 150/86 T 98.0 oral P 100 R 22, non-labored;
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: inspiratory crackles
HEART: Normal S1 with S2 split during expiration. An S4 is noted at the apex; systolic murmur noted at the right upper sternal border without radiation to the carotids.
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
GENITOURINARY: no CVA tenderness; not examined
MUSCULOSKELETAL: Heberden's nodes at the DIP joints of all fingers and crepitus of the bilateral knees on flexion and extension with tenderness to palpation medially at both knees. Kyphosis and gait slow, but steady.
PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22.
SKIN: Sparse hair noted on lower legs and feet bilaterally with dry skin on her ankles and feet.
Labs:: Hgb 12.2, Hct 37%, K+ 4.2, Na+140, Cholesterol 230, Triglycerides 188, HDL 37, LDL 190, TSH
3.7, glucose 98 BUN 12 Cr 0.8 A:
Primary Diagnosis:
Congestive Heart Failure (CHF) (150.9) Secondary Diagnoses: Primary Hypertension (I10) Depression F32.3:
Obesity (E66):
Osteoarthritis (OA) (715.90) Differential Diagnosis:
Peripheral Vascular Disease (PVD) (173.9) P:
Medications:
[Show More]
