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NR 601 Week 2 Parts 1 and 2 Assignment
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
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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: …