S.P. is a 75-year-old woman who presents to the provider's office with fatigue.
Subjective Data
PMH: HTN, hyperlipidemia, MI 3 years ago
Fatigue started about a month ago, getting worse
Relieved with rest, exacerbated with activity
Denies chest pain
Ankles swollen
Objective Data
Vital signs: T 37 P 112 R 18 BP 110/54
Lungs: bilateral lower lobe crackles
O2 Sat = 94%
Skin = cool to touch
CV = heart rate regular, positive peripheral pulses, ECG = no changes
+2 edema bilateral ankles
Medications: Metoprolol 20 mg per day, 325 mg of aspirin per day
Questions
Already registered? Login
Not Account? Sign up
Enter your email address to reset your password
Back to Login? Click here