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B.J., a
70-year-old Caucasian female has been seen in the clinic several
times over the last 3 years. However, she missed her last annual
appointment-last appointment was 18 months ago and today you are the nurse
practitioner seeing her. She arrived to the clinic alone and states she is
“here for my check-up”.
Background:
PMH:
Chronic
back
2010-Left
Anterior Descending (LAD) cardiac stent placement
Allergies:
Amoxicillin
Vaccination History:
She
receives an annual flu shot. Last flu shot was this year
Has
never had a Pneumovax
Has not
had a Td in over 20 years
Has not
had the herpes zoster vaccine
Other
Differential Diagnosis:
Heart Failure,
Unspecified
Rationale:
The
reported symptoms of distal tingling and burning in her feet supports the
diagnosis of the condition neuropathy which includes paresthesia pain,
sensation of burning in affected area (Hennion & Siano, 2013).
Peripheral Arterial Disease
I73.9 (“icddata.com,” 2016)
Peripheral
arterial disease (PAD) is atherosclerosis leading to narrowing of the major
arteries distal to the aortic arch. It can involve both the upper and lower
extremities. Progressive occlusion results in arterial stenosis, reduced blood
flow, and claudication (Hennion & Siano, 2013).
HPI:
Onset:
Not specified
Location:
lower extremities. Chest
Duration:
All the time, worse at night
Characteristics:
burning, tingling, fatigue, SOB
Aggravating
Factors: activities, exertion, Nighttime
Relieving
Factors: pill taken under tongue
Treatment:
pill under tongue
Current medications:
Coreg
6.25 mg PO BID
Allergies:
Allergic to amoxicillin, No history of asthma, hives, eczema or rhinitis.
PMH:
Chronic
back pain
Hypertension
Social history:
She
graduated from high school, and thought about college, but got married right
away and then had kids a short time later. Her two sons and their wives live
with her, take her to church and to the local senior center; they do all the
cleaning, run errands, and do grocery shopping.
Family
history:
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