Charting Assg. 2

Charting Assignment # 2 Total points = 25

Joan is a 59-year-old African American female who presents to your clinic with a BP of 168/90, morning headaches and feeling like her heart is beating “ too fast”. She reports having a headache at least 2 times a week when she first wakes up in the morning. She came to your clinic today because she felt some lightheadedness, chest tightness and feeling like her heart was beating fast but states the chest tightness had gone away by the time she finished her shower this morning. She states she has never been told that her blood pressure was high but also states she has not been seen by a doctor in about 2 years.

 

She denies any past medical history but when asked about her family history she states her father died of a heart attack and her mother has heart failure. She admits to smoking 2 packs of cigarettes a day and leads a sedentary life outside of work. She states she drinks 2-3 beers about 4-5 times a week and admits to drinking more on the weekends. She is married, and states her oldest son was killed in a car accident 2 months ago. She denies any prescription medications but takes an over the counter daily multivitamin and takes a daily aspirin because she read it can help keep her from having a heart attack.

 

Your medical assistant reports her Vital Signs as follows: BP on arrival 168/92 after 20 minutes, repeat BP is 168/90, P= 114, R =20, T= 98.2F and her height = 6ft 2 inches.

weight 255 pounds and BMI =33

 

Your physical exam findings are as follows:

 

General: Appears older than her stated age; frowning

 

HEENT: Cranial Nerves intact

 

Neck: No lymphadenopathy

 

Skin: warm and dry

 

Respiratory: Lungs sounds clear bilaterally, unlabored

 

Cardiovascular: No jugular venous distention at 30-degree elevation. Heart sounds strong3/4; grade 2/6 systolic murmur at left sternal border, 5th ICS. Abdominal and peripheral vascular assessments negative; pedal and post tibial pulses 2+/4+

 

Abdomen: tender over right upper quadrant; Liver border within normal limits; spleen and kidneys unremarkable

 

Neuromuscular: Romberg’s sign negative; gait relaxed and symmetrical, no pronator drift. Full ROM all extremities.

 

 

 

1. What are the most pertinent 3-5 questions would you ask this client based on the subjective information provided? Include your evidenced-based rationale for each of your questions. 5 points

 

2 .Identify 3 differential diagnoses based on the subjective and objective findings provided

and rule each one in and out including your rationale based on pertinent data provided

5 points

 

 

3. Based on the subjective and diagnostic data provided, discuss what diagnostic

procedures need to be ordered and why? 5 points

 

4. Identify your definitive and / or working diagnosis(es) / assessments) based on the pertinent

subjective and objective findings provided. Include your pharmacological, non-

pharmalogical treatment plan including health promotion interventions. 5 points

 

5. Discuss the type of physical exam and SOAP note that is required given the

subjective and objective provided including your evidenced-based rationale.

5 points