clinic

Patient Initials __KM____
Subjective Data
Chief Compliant: Mrs. KM presented to clinic today complaining of wheezing, shortness of breath and coughing at least once a day. She stated that she was discharged from the hospital ten weeks ago due to motor vehicle accident.
History of Present Illness: Mrs. Mk has been experiencing severe frequent asthma attacks at the frequency of not less than four time a week for the past two months following serious motor vehicle accident ten weeks ago. She also experienced seizure two weeks after the accident that subsided after she was placed on dilantin. medication.
PMH/Medical/Surgical History: Mrs. King had extensive medical history of asthma since her early 20s. She was diagnosed three years ago for mild congestive heart failure. She also had episode of seizure activities following motor vehicle accident ten weeks ago and congestive heart failure since last year. She is currently taking theophylline sr 300 mg capsules by mouth two time a day for asthma, albuterol inhaler as needed for asthma, phenytoin sr 300 mg cap by mouth at bedtime for seizures, HTCZ 50 mg by mouth two times a day for congestive heart failure, enalapril 5 mg by mouth two times a day for worsening congestive heart failure and sodium restrictive diet for chf. She has no known allergies.
Significant Family History: Her father died of kidney failure at age 59 secondary to hypertension and her mother died at age 62 due to congestive heart failure.
Social History: This is a 65 years old Caucasian female who doesn?t smoke nor drink alcohol. She drink 4 cups of caffeine and diet colas. She doesn?t exercise due to shortness of breath and has no history of family violence. She is pale and well developed female with period of aniety.
Review of Symptoms: (Review each body system – This section you should place POSITIVE for? information in the beginning then state Denies?). – General: denies problem, well developed; Integumentary: Pale, skin intact; denies of infection; Head: denies of headache; Eyes: denies of visual change, no signs of inflammation, no nystagmus ; ENT: denies ear pain, oral cavity without lesions: positive cough; Cardiovascular: positive hypertension, tachycardia and congestive failure; denies chest pain, palpitation; Respiratory: positive shortness of breath, coughing, wheezing and exercise tolerance; Gastrointestinal: denies abdominal pain, nausea, vomiting or diarrhea; Genitourinary: denies difficulty urinating; Musculoskeletal: positive swelling in the extremities; Neurological: positive seizure; Endocrine: denies diabetes; Hematologic: denies bleeding or unusual bruising; Psychologic positive anxiety .
Objective Data:
Vital Signs: BP 171 – 94; P122 ; R 31; T 96.7; Wt. 145; Ht.5? 3? ; BMI .
Physical Assessment Findings: (Includes full head to toe review)
HEENT: PERRLA
Lymph Nodes: none palpable
Carotids: normal
Lungs: bilateral expiratory wheezes
Heart: regular rate and rhythm normal S1 and S2
Abdomen: soft, non tender, non distended no masses
Genital/Pelvic: unremarkable
Rectum: guaiac negative
Extremities/Pulses: +1 ankle edema, on right, no bruising, normal pulses.
Neurologic: A&OX3, cranial nerves intact, no seizures.
Laboratory and Diagnostic Test Results:
Na ? 134
K ? 4.9
Cl ? 100
BUN ? 21
Cr ? 1.2
Glu ? 110
ALT ? 24
AST ? 27
Total Chol ? 190
CBC WNL
Theophylline ? 6.2
Phenytoin ? 17
Chest Xray ? Blunting of the right and left costophrenic angle
Peak Flow ? 75/min; after albuterol ? 102/min
FEV! ? 1.8L: FVC 3.0 L, FEV1/FVC 60%
Note: all labs are within normal limit except sodium that is slidely below normal range.
Assessment:
ICD ? 10 Diagnosis/Client Problems (CMS.gov,n.d.)
Asthma
Congestive heart failure
Shortness of breath
Anxiety disorder
Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided).
Please address each of the above four diagnosis the same way you did the last cardiovascular care plan.
Please include the introduction paragraph
Conclusion and
The references
References