Week 3 Case Discussion: Cardiovascular Patient Information: Lorene, 60-year-old African American female, insurance unknown. SOAP S: Lorene’s chief complaint is shoulder discomfort and shortness of breath following exercise that started three days ago. She felt "a discomfort" radiating back and up...
This study source was downloaded by 100000849840424 from CourseHero.com on 03 -07-2023 09:42:17 GMT -06:00 https://www.coursehero.com/collection/6480406 2/nr603 -week -3-cardiovasculardocx/ NR 603 WEEK 3 CASE DISCUSSION : CARDIOVASCULAR Week 3 Case Discussion: Cardiovascular Patient Information: Lorene, 60-year-old African American female, insurance unknown. SOAP S: Lorene’s chief complaint is shoulder discomfort and shortness of breath following exercise that started three days ago. She felt "a discomfort" radiating back and up between her shoulder blades. She also experienced feelings of nausea as well as sweat. However, these symptoms were resolved 3 minutes after exercises and have not recurred. The patient reports currently not being on medication after stopping Lisinopril that she was on, citing learning its side effects. Hx allergy to metformin, GI disturbance. PMH: Admits challenge to make healthy food choices. Exercise and diet has been the patient’s weight loss routine. The patient feels a little more tired than usual since stopping workout after chest pain. Chronic illnesses: Hypertension, Dyslipidemia, and Metabolic Syndrome. Moreover, gestational Diabetes has been experienced in the last 3 pregnancies which was managed with Insulin. Surgeries: T and A, cholecystectomy Childhood/previous illnesses: chickenpox. Immunization: None. Does not receive the flu shot. Soc Hx: Reports being a married for the last 20 years. Patient regularly eats out and consumes beer, wine, or cigarettes while entertaining clients on a weekly basis as part of her role as a CEO of a marketing company. Fam Hx: Lung cancer (father), mother (stroke and diabetes type 2), brother (malignant melanoma), sister and brother (metabolic syndrome) ROS: CONSTITUTIONAL : Reports increased fatigue as of 3 days ago. Planned weight loss. Does not report experiencing fever or chills. HEENT : None SKIN : None. This study source was downloaded by 100000849840424 from CourseHero.com on 03 -07-2023 09:42:17 GMT -06:00 https://www.coursehero.com/collection/6480406 2/nr603 -week -3-cardiovasculardocx/ NR 603 WEEK 3 CASE DISCUSSION : CARDIOVASCULAR CARDIOVASCULAR : Experiences shortness of breath, chest heaviness, sweating, and nausea. RESPIRATORY : Shortness of breath 3 days ago, none since. No sputum reported. GASTROINTESTINAL : Nausea as of 3 days ago. GENITOURINARY : None. NEUROLOGICAL : None. MUSCULOSKELETAL : None HEMATOLOGIC /LYMPHATICS : None. PSYCHIATRIC : None. ENDOCRINOLOGIC : None. ALLERGIES : None. O: Vital signs: BP 146/90 P 70 SaO2 97% Height 5'8", Weight 220 pounds, BMI 33.5 General: African American female in NAD. Alert, oriented, and cooperative. Pain: 0/10 now. Skin: Warm, dry, and intact. Light brown in color. No cyanosis or pallor. HEENT: Head normo -cephalic. Thick and evenly distributed hair. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. No AV nicking noted. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus are non-tender. Nose: Nares patent without exudate. Sinuses nontender to palpation, Right -sided Deviation Throat: Oropharynx moist, no lesions, or exudate. Teeth in poor repair, gums reddened and receding, filled cavities noted. Tongue smooth, pink, no lesions, protrudes in the midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Mild JVD in a recumbent position Lungs: Lungs clear to auscultation bilaterally. Respirations are unlabored. No rashes or vesicles noted on the chest.
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