S: MJ is a 74 year old African-American female who presents to the clinic today with complaints of shortness of breath with exertion and increasing fatigue over the past two to three months. The shortness of breath is increased with exercise or when walking up stairs and has progressively gotten worse. She states that she presented to the emergency room approximately one year ago for shortness of breath and was prescribed an albuterol inhaler. She additionally has a chronic productive cough with clear sputum and denies hemoptysis. She has had no recent upper respiratory infections and denies fever. She denies chest pain or tightness. She also states that she has noticed some ankle edema over that has developed over the past year.
PMH: includes hypertension, hyperlipidemia, and osteoarthritis
Past surgical history: total knee arthroplasty in 2008
SH: includes a 35 pack-year history for cigarettes, quit 5 years ago. Drinks socially, approximately 2-3 glasses of red wine per week
Medications: Metoprolol 25mg daily, Hydrochlorothiazide 25mg daily, Pravastatin 10mg daily
Allergies: No known drug allergies
Subjective information collected by the family nurse practitioner (FNP) is essential to appropriately manage chronic disease. Although a sufficient amount of subjective data was collected to properly manage the patient, there was additional pertinent data that could have been collected. A family history should have been included in the encounter. The provider should have inquired about conditions such as cystic fibrosis, COPD, tuberculosis, or a1-Antitrypsin deficiency (Boardman, 2013, p. 446). Additional inquiry regarding occupational history and exposure to noxious inhalants was also warranted (Boardman, 2013, p. 446). Finally, the provider should have elicited additional information regarding frequent respiratory infections or if there was a past history of asthma.
VS: BP 152/85 T 97.8 P 62 R 24 O2 95% on RA BMI 24
General: 75 y/o well-nourished female in mild distress
HEENT: Head normocephalic. Eyes: Conjunctiva without erythema. PERRLA. EOM intact. Ears: TMs pearly gray without effusion or exudate. Nose: Nares patent. Turbinates without erythema. Throat: Pharynx without erythema.
Lungs: Diminished breath sounds throughout; wheezes auscultated in bilateral bases
Cardiovascular: HRR with normal S1/S2, no murmurs/rubs/gallops; bilateral lower extremity edema noted; No JVD
Abdomen: soft and non-distended; no hepatosplenomegaly; BS +
Neuro: Cranial nerves II-XII grossly intact
Musculoskeletal: Strength 5/5 in all extremities; Normal ROM
The above physical examination provided sufficient information to determine an appropriate assessment and plan of care for the patient, however there was additional information that could have been collected. When assessing a patient presenting with shortness of breath, the nails should be inspected for clubbing. Additionally, the patient’s anteroposterior...