FNP 590 - Health Promotion, Education, and Disease Prevention Across the Life Span

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 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,