NR 601 MAT ADLT WEEK 2 PART 1 AND PART 2
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NR 601 MAT ADLT WEEK 2 PART 1 AND PART 2
B.J., a 70-year-old Caucasian female has been seen in
the clinic several times over the last 3 years. However, she missed her last
annual appointment-last appointment was 18 months ago and today you are the
nurse practitioner seeing her. She arrived to the clinic alone and states she
is “here for my check-up”.
Background:
PMH:
Chronic back
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
Other
Differential Diagnosis:
Heart Failure, Unspecified
Rationale:
The reported symptoms of distal tingling and burning in her feet
supports the diagnosis of the condition neuropathy which includes paresthesia
pain, sensation of burning in affected area (Hennion & Siano, 2013).
Peripheral Arterial Disease
I73.9 (“icddata.com,” 2016)
Peripheral arterial disease (PAD) is atherosclerosis leading to
narrowing of the major arteries distal to the aortic arch. It can involve both
the upper and lower extremities. Progressive occlusion results in arterial
stenosis, reduced blood flow, and claudication (Hennion & Siano,
2013).
HPI:
Onset: Not specified
Location: lower extremities. Chest
Duration: All the time, worse at night
Characteristics: burning, tingling, fatigue, SOB
Aggravating Factors: activities, exertion, Nighttime
Relieving Factors: pill taken under tongue
Treatment: pill under tongue
Current medications:
Coreg 6.25 mg PO BID
Allergies: Allergic to amoxicillin, No history of asthma,
hives, eczema or rhinitis.
PMH:
Chronic back pain
Hypertension
Social history:
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.
Family history:
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