Case Study Lena Assignment Help: How to Answer This Question
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Original Question
Case Study: Mrs. Lena Gonzales, a 68-year-old woman, presents to your office today with a complaint of feeling tired all the time and now, more recently, feeling weak. She states on this visit, “I can’t catch my breath sometimes.” 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. She is a retired school teacher and has two daughters living nearby and 3 grandchildren she sometimes watches for her daughter. She has a close relationship with her daughters and their families. They have been a big source of support since her husband’s death. At this visit she appears tired. HPI – as stated in case above. Allergies: No known drug allergies. Medications: • Lipitor 10 mg po q H.S. • Ashwagandha 2100mg 2 caps daily – supplement for mood. PMH: As stated in case above. PSH: Appendectomy in childhood; hysterectomy for uterine myoma 10 years ago. VS: BP 106/70 Pulse 108 Resp 18 Temp 98.2 Ht 65 inches Wt 134 lbs BMI 22.3 Diagnostics/Assessments: Urine dipstick negative. The results of a recent colonoscopy show questionable neoplasm in the colon. 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. In the Plan section, list the treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. Give rationales as to why and use up to date journal articles to cite. A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. Give rationales as to why and use up to date journal articles to cite.
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