A 48 year old male patient who is an electrician whom you haven’t seen in several years presents with chronic fatigue and mild chest pain frequently relieved by taking a break from working overhead. He’s married to a 47-year-old woman with MS and has two married children and one grandchild living nearby. He also complains of frequent eructation, flatulence, and indigestion after eating. He was told when he was 30 lbs. lighter that he could control his hyperlipidemia by diet.
CC: “I’m always tired, and I have this annoying chest pain when I climb a ladder.”
Past medical history: Anxiety, cholecystectomy, vasectomy
Vital signs: Blood pressure: 146/88; height, 6΄΄; weight, 242 lbs.
Lab results:
TC 230
LDL 180
HDL 32
Glucose: 178
Hgb 12
Hct 36
MCV 78
Questions:
1. What additional subjective data do you think the patient will share?
2. What additional objective data will you be assessing for?
3. What National Guidelines are appropriate to consider? What level of evidence supports these guidelines?
4. What tests will you order?
5. Will you be looking for a consult?
6. What are the medical and nursing diagnoses?
7. Are there any legal/ethical considerations?
8. What is your plan of care?
medical
nursing
complementary therapies
9. Are there any Healthy People 2020 objectives that you should consider?
10. Using the Circle of Caring, what or who else should be involved to truly hear the patient’s voice, getting him and the family involved in the care to reach optimal health?
11. What additional patient teaching is needed?
12. What billing codes would you recommend?
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