MSN 610 Diagnostic Reasoning and Advanced Physical Assessment Case Study 4A
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Course
MSN 610
Institution
MSN 610
A 68 year- old female returns for a follow up at the primary care clinic. She has a known history of Paroxysmal Atrial
Fibrillation. She states she has felt her heart “go out of rhythm” several times since her last appointment 3 months ago.
She has not seen her cardiologist in over a year. Th...
msn 610 diagnostic reasoning and advanced physical assessment case study 4a
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MSN 610
MSN 610
Diagnostic Reasoning and Advanced Physical Assessment
Case Study 4A
A 68 year- old female returns for a follow up at the primary care clinic. She has a known history of Paroxysmal Atrial
Fibrillation. She states she has felt her heart “go out of rhythm” several times since her last appointment 3 months ago.
She has not seen her cardiologist in over a year. The irregular rhythm has been occurring 2-3 x/week for the last 2
months lasting 1-5 minutes.,
Family History: Father deceased at age 80 with CVA
Mother deceased at age 78 with HTN, DM II, Glaucoma, Hypothyroidism
1 Sister living at age 65 with CAD s/p CABG
Social History: Lives alone in a condo. Retired from teaching school. She denies ever smoking or use of alcohol. She
admits to consuming “iced tea” all day long. Her diet consists of cereal and fruit for breakfast, a sandwich or salad for
lunch and/or dinner.
ROS:
General: Denies weight gain or loss, fatigue, fever or chills
Cardiac: Denies chest pain or dyspnea, Admits to palpitations as described in HPI, Also admits to increased ankle swelling
Resp: Denies cough, wheezing, PND
Heme: Denies acute bleeding or melena but admits to frequent bruising
General: Well groomed, Alert, Oriented, Cooperative, 68 yo female who appears her stated age in NAD
Neck: Mild JVD, Trachea midline, No Thyromegaly, No lymphadenopathy, Carotid Pulse Irregular
COR: Irregular S1S2 with early systolic Murmur (III/VI) at 4 th ICS MCL
Lungs: CTA with equal bilateral expansion. No abnormal tactile fremitus. No wheezing or rhonchi heard. Fine bibasilar
rales present
Extremities: + 2 ankle edema bilaterally, Radial pulses equal @ +2, Pedal Pulses equal @ +1
Her EKG rhythm strip is:
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