Case Study #1Instructions:Read the following scenario carefully: list the abnormal components of the physical exam and give indications for each abnormality. List appropriate diagnostics (labs, imaging, etc.) that you would expect to be ordered according to the symptoms, and give a brief explanation for why each diagnostic test was ordered. Next, give a primary nursing diagnosis with 3 additional nursing diagnosis along with corroborating evidence supporting each diagnosis. Give main etiology (cause) for primary diagnosis. Outline treatment plan, including medications, for patient related to the primary diagnosis. ASSIGNMENT SHOULD BE AT LEAST 2 PAGESHPI:A 64 y/o male presents to the office with 3 months of exertional dyspnea. The past 2 weeks, the dyspnea has worsened, and the patient experiences dyspnea at rest. The patient also complains of orthopnea. A productive cough with “pink stuff” has been present for 5 weeks, and is worsening as well.PMH:Patient has a history of allergic rhinitis, depression, HTN, and osteoarthritis.
PSH:Patient has no prior history of any surgeries.
FH:Mother has a history of HTN and depression; and is currently decreased. Father has a history of DM type 2 and HTN; and is also currently deceased. Maternal grandfather had a MI when he was 68, has a history of HTN, and is decreased. Patient has no other information regarding grandparents other than they are deceased.SH:Patient lives at home with his wife. Patient is a retired engineer. Patient states that he has a good network of family and friends around for support, and that his religious affiliation is Baptist.Medications:Sertraline 50 mg PO daily for depressionHydrochlorothiazide 12.5 mg PO daily for HTNFlonase 2 sprays (50 mcg of fluticasone propionate each) in each nostril once daily (total daily dose, 200 mcg) for allergic rhinitisIbuprofen 1200 milligrams (mg) up to 3200 mg per day divided into three or four equal doses.
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