S.P. is a 75-year-old woman who presents to the provider's office with fatigue. Subjective DataPMH: HTN, hyperlipidemia, MI 3 years agoFatigue started about a month ago, getting worseRelieved with rest, exacerbated with activityDenies chest painAnkles swollen Objective DataVital signs: T 37 P 112 R 18 BP 110/54Lungs: bilateral lower lobe cracklesO2 Sat = 94%Skin = cool to touchCV = heart rate regular, positive peripheral pulses, ECG = no changes+2 edema bilateral anklesMedications: Metoprolol 20 mg per day, 325 mg of aspirin per day1. 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?

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Answered: S.P. is a 75-year-old woman who…

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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?