Review the attached case in Moodle and list the top three problems that you feel are most important to target first. Need at least a page response!
Then, ask at least one other healthcare team member in a profession different from yours [could be a student (in this class or not) or a working professional] to review the case and list the top three problems they felt were most important to target first.
Complete an associated write-up. A component of your write-up should describe this activity and detail the differences and similarities (if any). Please include the name of the person who completed the case and basic details about their profession or the profession they are studying in school.
CC: 55 year old female concerned with cough and fatigue “I have completely had to stop swimming due
to my cough and fatigue.”
Vital signs: P 90, RR 20, BP 150/90 (sitting), T 98.6; Height 5’3” Weight 190 lbs
HPI: 3 weeks persistent cough with concurrent fatigue and shortness of breath with exercise. Overall
symptoms are intensifying and worsening. Cough productive of white sputum day and night. Sleeping
in recliner to reduce cough and improve SOB. Was swimming an hour per day X 3 months, for the past 3
weeks unable to take the bus to the pool d/t fatigue and SOB. Tried to decrease symptoms with
Albuterol inhaler, and by taking GERD medication, but they make little difference.
Diet: “Not hungry.” Cheerios for breakfast with 2% milk and coffee; lunch Diet Coke # 2 cans and
Campbell’s chicken noodle soup; dinner is noodles in a cup, several cookies, and Diet Coke; coffee or
soda 6-7 cups per day
Emotions: Tired mood is flat and low
Works: Does not work outside of the home, but did care for grandson
Sleep: “Disturbed” by frequent awakening
PMH: Asthma with fair control, GERD, Diabetes type 2 (recent A1c 9.2%)
Surgeries: C-section, abdominal hernia repair
Medications: Lisinopril 20 mg daily; Amlodipine 10 mg daily; Albuterol Inhaler prn wheezing;
Omeprazole 20 mg BID for GERD sx; Simvastatin 40 mg every evening for hyperlipidemia; Metformin
500 mg BID for diabetes; Benadryl (Diphenhydramine) prn for seasonal hay fever
– Admits to missing medications at least 3 times per week
Allergies: Grass and cats
Family History: Mother died @ 82 yrs: “heart problems” and morbid obesity
MGM and MGF died of MI in their 70s
Father died at 55yrs: MI, his second with first being at age 45; diabetes 2
Father adopted and FH paternal family history unknown
Social: Lives alone; did care for grandson; recently son placed in jail, unjustly; grandson was removed
from patient’s care; she is very distressed; feels guilty that cannot help son/grandson
Habits: Smokes 1 pack per day, no ETOH, no illicit drug use
Immunizations: Influenza vaccine last November
ROS:
General: + Fatigue, + 8 lbs weight gain (cumulative over past 3 weeks), denies fever/chills, malaise,
some night sweats
HEENT: no recent URI/sinusitis/infections treated with antibiotics
Lungs: + SOB, cough, orthopnea, and some wheezing
Heart: + LE edema + varicosities; no chest pain, palpitations, fainting
Abdomen: Frequent heartburn and associated substernal pain, some nausea, no vomiting, or diarrhea;
some constipation—brown and hard stools responsive to Metamucil; no bright red bleeding or black
stools
Psych/Mental health: Feeling “blue;” misses son and grandson; misses being able to swim; energy level
is diminished.
Sleep: awakening ~ 1:00, 3:00, 5:00 AM and has difficulty in returning to sleep; interest in life is
diminished and concentration slightly diminished because of fatigue; no suicidal ideation or plan;
functionally does the best that is able to do, but is profoundly fatigued.
Physical Exam:
Vital signs: P 90, RR 20, BP 150/90 (sitting), T 98.6; Height 5’3” Weight 190 lbs
Appearance: Alert and oriented X 3, teary when speaks of son/grandson; good memory, both remote
and recent, little spontaneity.
Psych/mental health: Appearance: casually dressed; Behavior: blunt affect; tears easily; Cognition:
answers to questions with logical responses; Thoughts: thoughts fairly well linked together
Skin: no lesions, 2+ lower extremity edema
Thyroid: normal size, shape, consistency
Reflexes: patellar 2+; Achilles 0 symmetric
Lungs: Slightly winded walking to and ascending exam table; AP: transverse 1:1, CTA with scattered
wheezes and rales bilaterally posterior bases
Heart: Irregular rhythm, PMI difficult to palpate, S1S2 s murmur, bruit, gallop, rub; JVD 4 cm @ 45
degree angle
Abd: Rounded, BS X 4, no aortic or renal bruits, tympany predominates, no
tenderness/guarding/rebound, no masses or hepato/splenomegaly; + hepatojugular reflex; no CVA
tenderness
LE: + 2 pitting edema, 1+ PT and DP pulses; + LE varicosities R > L