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 1. Develop a problems list from the objective and subjective data. What should be included in the plan of care? Based on the readings, what is the most likely cause of fatigue for this patient?

Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
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  1. 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

    1. Develop a problems list from the objective and subjective data.
  2. What should be included in the plan of care?
  3. Based on the readings, what is the most likely cause of fatigue for this patient?
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