THE CASE STUDY OF MRS. LOPEZ 1
FNP 590 - Health Promotion, Education, and Disease
Prevention Across the Life Span
The Case Study of Mrs. Lopez - An Integrative Approach
Nicole Scribner
United States University
FNP 590 - Health Promotion, Education, and Disease Prevention Across the Life
Span Professor Shauna Chriss
June 18, 2021
This study source was downloaded by 100000834306259 from CourseHero.com on 04-29-2022 13:08:50 GMT -05:00
https://www.coursehero.com/file/107538592/FNP-590-Signature-Assignment-Case-Studydocx/
, THE CASE STUDY OF MRS. LOPEZ 2
The Case Study of Mrs. Lopez - An Integrative Approach
Subjective: Mrs. Lopez is a 58-year-old Hispanic widow. She is unemployed and
currently lives with her son and daughter and law, and her three grandchildren. She in not
currently sexually active. She is catholic and very involved with her church and family. Her
insurance is Medicaid. She is independent and does not require assistance from her family. The
patient predominantly uses folk remedies to treat any illness and therefore has not seen a primary
care provider in several years. She comes to the clinic for a check-up and exam, and reports
some difficulty with breathing and history of asthma, but denies any other medical problems.
The patient has a surgical history of a tonsillectomy. She currently takes no prescription
medication, but does use herbal supplements. Patient reports that she once used and inhaler but
stopped using it because she could no longer afford it. The patient reports that she is a smoke and
smokes ½ a pack a day. She also drinks but she reports only socially, 3-4 times a month. She
reports that her mother died from a stroke and that her father had diabetes. The patient has
NKDA. Patient is currently unsure of her immunization and vaccination status.
Objective: physical exam includes, Vital signs: Ht. 62 inches, Wt. 165 lbs., BP: 156/94,
HR: 86, RR: 19, SaO2: 85% on RA. HEENT: denies headaches, or ear, nose, and throat pain,
mucous membranes pink, moist, and intact, tonsils have been removed, missing some teeth,
tongue pink, intact, and midline, no lymphadenopathy. Cardiovascular: Denies chest pain or
palpitations, S1 & S2, no murmur, rhythm is regular, no tachycardia. Respiratory: Report’s
shortness of breath and chronic non-productive cough, Inspiratory and expiratory wheezes heard
bilaterally. GI: Denies heartburn, nausea, vomiting, pain, diarrhea, or constipation, physical exam
WNL. GU: Denies, Musculoskeletal: Reports mild generalized joint pain, limited ROM in
bilateral knees and shoulders. Neurological: Denies, Psychiatric: Denies depression, anxiety,
This study source was downloaded by 100000834306259 from CourseHero.com on 04-29-2022 13:08:50 GMT -05:00
https://www.coursehero.com/file/107538592/FNP-590-Signature-Assignment-Case-Studydocx/
FNP 590 - Health Promotion, Education, and Disease
Prevention Across the Life Span
The Case Study of Mrs. Lopez - An Integrative Approach
Nicole Scribner
United States University
FNP 590 - Health Promotion, Education, and Disease Prevention Across the Life
Span Professor Shauna Chriss
June 18, 2021
This study source was downloaded by 100000834306259 from CourseHero.com on 04-29-2022 13:08:50 GMT -05:00
https://www.coursehero.com/file/107538592/FNP-590-Signature-Assignment-Case-Studydocx/
, THE CASE STUDY OF MRS. LOPEZ 2
The Case Study of Mrs. Lopez - An Integrative Approach
Subjective: Mrs. Lopez is a 58-year-old Hispanic widow. She is unemployed and
currently lives with her son and daughter and law, and her three grandchildren. She in not
currently sexually active. She is catholic and very involved with her church and family. Her
insurance is Medicaid. She is independent and does not require assistance from her family. The
patient predominantly uses folk remedies to treat any illness and therefore has not seen a primary
care provider in several years. She comes to the clinic for a check-up and exam, and reports
some difficulty with breathing and history of asthma, but denies any other medical problems.
The patient has a surgical history of a tonsillectomy. She currently takes no prescription
medication, but does use herbal supplements. Patient reports that she once used and inhaler but
stopped using it because she could no longer afford it. The patient reports that she is a smoke and
smokes ½ a pack a day. She also drinks but she reports only socially, 3-4 times a month. She
reports that her mother died from a stroke and that her father had diabetes. The patient has
NKDA. Patient is currently unsure of her immunization and vaccination status.
Objective: physical exam includes, Vital signs: Ht. 62 inches, Wt. 165 lbs., BP: 156/94,
HR: 86, RR: 19, SaO2: 85% on RA. HEENT: denies headaches, or ear, nose, and throat pain,
mucous membranes pink, moist, and intact, tonsils have been removed, missing some teeth,
tongue pink, intact, and midline, no lymphadenopathy. Cardiovascular: Denies chest pain or
palpitations, S1 & S2, no murmur, rhythm is regular, no tachycardia. Respiratory: Report’s
shortness of breath and chronic non-productive cough, Inspiratory and expiratory wheezes heard
bilaterally. GI: Denies heartburn, nausea, vomiting, pain, diarrhea, or constipation, physical exam
WNL. GU: Denies, Musculoskeletal: Reports mild generalized joint pain, limited ROM in
bilateral knees and shoulders. Neurological: Denies, Psychiatric: Denies depression, anxiety,
This study source was downloaded by 100000834306259 from CourseHero.com on 04-29-2022 13:08:50 GMT -05:00
https://www.coursehero.com/file/107538592/FNP-590-Signature-Assignment-Case-Studydocx/
