Identifying data:name: Ms. Gee, age: 68, gender: Female,… Identifyin

Identifying data:name: Ms. Gee, age: 68, gender: Female,… Identifying data: name: Ms. Gee, age: 68, gender: Female, occupation: retired teacher, reliability: reliable historian S)  CC: palpitations HPI: Pt complains of palpitations since beginning of year that lasts 30 seconds to a minute. Sx are more prevalent after walking 2-3 miles with dog. Easily “winded” after walk, becomes more tired easily and progressively getting worse.  Sx come and go. No associated chest pain. States “heart beats really fast and hard”.  PMH:  Childhood illnesses (if pertinent): N/A                                  Medications: Atorvastatin 10mg po qhs, HCTZ 2.5mg qam, multivitamin occasionally Adult illnesses:   Medical: HTN                                 Allergies (meds, food,  environment): NKDA, seasonal allergies                            Surgical: cholecystectomy @ age 40, no hospitalizations, or other surgeriesOb/gyn: no menses, last pap couple of years ago. Pap smear was clear a   couple years ago, sexually active                            Psych: N/A, feels goodHCM:   immunizations: UTD including Tdap and flu, COVID vaccine x 3 screening tests: Covid neg, colonoscopy UTD  FH:      Father: 78 years old deceased d/t heart attack; Hypertension and High CholesterolMother: 73 years old deceased d/t breast cancer, otherwise healthySister – 59 years old, recently diagnosed with HTN  SH:      Married,—2 sons grown and married, w/ grandchildren takes to park. 1 dog            Exercise: walks x 2, 3 miles /day, pilates class x2—wants to check palpitations first            Diet: enjoys food deliveries, going out, cook at home and veggiesSafety measures (seat belts, bicycle helmet, sunblock, smoke detectors, locked firearms): all safeTobacco: smoked x since 18 (half pack/day), about 20 yearsAlcohol/drugs: 1 glass of wine with dinner, no illicit drugs             ROS:General: afebrile, denies fatigue, body aches, chillsDerm: no bruises on skin, no skin lesion, rashes or itchingHEENT: no loss of hearing, ear drainage, no sputum, no coughNeck: supple, full ROM, no nuchal rigidityBreasts: non tender, no discharge, no swelling*Respiratory: no sputum, no cough, no SOB, no tripoding*C-V: positive palpitations, no chest pain*GI: denies nausea, vomiting, diarrhea. No dark stoolsUrinary: N/AGenital:           Male:                        Female: N/APeripheral Vascular: no calf pain, swelling on calvesMusculoskeletal: no radiation to shoulder*Neurologic: no headache, no change in gait or speech,Hematologic: No general bleeding or dark stools Endocrine: N/APsychiatric: N/A   O)        General: NAD, AAxO x 3, cooperative, dressed appropriately, behavior appropriate, appears comfortable. VS:  BP 126/78, T 98.4; P:108,  R: 26, bmi: 26, O2 sat: 98% on RA            Skin: no rashes, skin color, no pallor, no cyanosis            HEENT: no dizziness, no syncope            Neck: no JVD            Thorax & lungs: S1 and S2, no MGR, irregular HR, no bruits, lungs clear ,non labored,Heart/pulses: S1 S2, no S3/S4, RRR, no MSG. No JVD. Pulses equal bilaterally, 2+, Irregular, no edema, normal capillary refill; No bruits.            Breasts, axillae, epitrochlear nodes: no lymphadenopathy            Abdomen: + BS in all 4 quads, no tenderness, no organomegaly            Lower extremities: no edema            Peripheral vascular: even pulses bilateral 2+, cap refill good, no pallor, no clubbing            Musculoskeletal:            Neurologic:     Mental status: no weakness, CN all intact, speech nl, no asymmetric, walks in room, ok moving in room                                    Cranial nerves: grossly intact                                    Motor system: grossly intact                                    Sensory system: grossly intact                                    Reflexes: grossly intact, No loss of coordination; Sensation: equal bilaterally            Genitalia: Not examined            Rectal: Not examined POCT(Results): EKG shows Afib, rate is 110 consistent, no sign of ischemia or infarction  A) Atrial Fibrillation  P)         Dx (Diagnostic tests, e.g. labs, x-rays, PFTs):            Rx (Prescriptions for meds, therapy, e.g. physical therapy; medical equipment, e.g. nebulizer, wheelchair):            Pt. Ed.(e.g. what you discussed together; handout materials):            F/U (Specific instructions for follow up, e.g. in 2 weeks for BP check; avoid “PRN”): I need help determining which medications and diagnostic testing this patient will need. She already got an EKG which showed A-fib and is already on HCTZ for HTN. Do I add a blood thinner and Digoxin or another type of HTN medication? Other than CBC and CMP, what other diagnositics does she need? Does she need immediate cardioversion in the ED?  Health Science Science Nursing N 671 Share EmailCopy link Comments (0)

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