Assignment: Nurse Practitioner
Case study:
Mrs. L., a 68-year-old woman, presents to your office today with a complaint of feeling tired all the time and now, more recently, feeling and like "I can't catch my breath sometimes."
HPI: She has been healthy except for high cholesterol, managed by Lipitor. Her husband died 9 months ago, and she has attributed her fatigue to dealing with his death but realizes that she is feeling worse and not better as time passes.
No known drug allergies.
Medications: Takes only Lipitor.
Past surgical history: Appendectomy in childhood; hysterectomy for uterine myoma 10 years ago.
No significant medical history. Has two daughters living nearby.
Blood pressure (BP) 106/70 mm Hg, heart rate (HR) 98 beats/min and regular, respiratory rate 18 breaths/min and afebrile, body mass index (BMI) 22 (10-pound weight loss since death of husband).
Slender, quiet-spoken older woman appearing tired.
PE: Conjunctiva pale, mucous membranes moist. No lymphadenopathy of neck or femoral area.
Heart tachyarrhythmia with regular rate, soft midsystolic murmur. Chest (CTA), good air movement.
Abdomen soft, bowel sounds × 4.
Diagnostics:
Urine dipstick negative.
The results of a colonoscopy show a neoplasm in the colon.
Address the following in your SOAP note:
1) What additional subjective data are you seeking?
2) What additional objective data will you be assessing for?
3) What medical history would you obtain from the patient? List at least three.
4) What tests will you order? Describe at least four lab tests.
5) What are the differential diagnoses that you are considering? Describe two.
6) What is your plan of care? List at least two diagnostic tests you will order to evaluate the cause of her condition.
Format your assignment according to the following formatting requirements:
(1) The answer should be typed, double spaced, using Times New Roman font (size 12), with one-inch margins on all sides.
(2) The response also includes a cover page containing the title of the assignment, the student's name, the course title, and the date. The cover page is not included in the required page length.
(3) Also include a reference page. The Citations and references should follow APA format. The reference page is not included in the required page length.