Georgina Graves is a 42-year-old female who presents to the provider's office with fatigue.
Subjective Data
PMH: none, (except gynecological issues)
Significant family history of heart disease
Fatigue started about 2 months ago, getting worse
Relieved with rest, exacerbated with activity
Denies chest pain
C/O shortness of breath on exertion
Smoker 1 PPD
Objective Data
Vital signs: T 37 P 100 R 18 BP 110/54
Lungs: clear
O2 Sat = 94%
Skin = cool to touch
CV = heart rate regular, positive peripheral pulses, ECG = intermittent complete left bundle branch block (New Finding)
Edema
Medications: Premarin 0.3 mg po/day
What other questions should the nurse ask about the fatigue?
What other assessments would be necessary for this patient?
What are some causes of fatigue?
What should be included in the plan of care?
Based on the readings, what is the most likely cause of fatigue for this patient?
Apa format required
Reference:Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders.
Chapter 18: Thorax and Lungs
pp. 413-441 (Structure, Function, The Thoracic Cavity, Developmental Competence, Subjective Data, Objective Data)
Chapter 19: Heart and Neck Vessels
pp. 459-492 (Structure and Function, Heart Wall, Chambers, and Valves, Heart Sounds, Developmental Competence, Subjective Data, Objective Data )
Chapter 20: Peripheral Vascular System and Lymphatic System
pp. 509-529 (Structure and Function, Lymphatics, Developmental Competence, Subjective Data, Objective Data)