CHANA KUMAR iHuman: FATIGUE OVER
THE PAST TWO MONTHS “chana Kumar is
an
86-year-old female…” SOLUTIONS
Includes: physical exams, MSAP, exercise questions, diagnosis, DDX, DDX
rankings, MNM, Case plan
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CHANA KUMAR iHuman: FATIGUE OVER THE PAST TWO MONTHS “chana Kumar is an 86-year-old fem, Exams of Nursing
CHANA KUMAR iHuman: FATIGUE OVER THE PAST TWO MONTHS “chana Kumar is an 86-year-old female…” SOLUTIONS Includes: physical exams, MSAP, exercise questions, diagnosis, DDX, DDX rankings, MNM, Case plan
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2024/2025
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CHANA KUMAR iHuman: FATIGUE OVER
THE PAST TWO MONTHS “chana Kumar is
an
86 - year-old female…” SOLUTIONS
Includes: physical exams, MSAP, exercise questions, diagnosis, DDX, DDX
rankings, MNM, Case plan
Chana Kumar H&P Patient Information Chana Kumar is an 86 - year-old female. History is provided by the patient, who is a reliable source. Chief Complaint Patient presents with the chief complaint of fatigue over the past two months. Present Illness Ms. Kumar stated that she had an alarming situation during her water aerobics class yesterday. She stated she gradually became shorter of breath and her heart started racing. When her instructor checked her heart rate, it was 120 beats per minute. She said her symptoms improved after resting for 30 minutes. Ms. Kumar has a history of hypertension in which is taking metoprolol 100mg daily and aspirin 81mg daily. She had a CABG performed 8 years ago. She also takes atorvastatin 20mg daily for her high cholesterol. Ms. Kumar also states that she has been feeling more fatigued, weaker, and easily winded over the past two months. She feels good waking up in the morning but gets tired throughout the day. She does get tired walking up stairs and around the block. Denies having difficulty with performing activities of daily living. She does states she has pain in her knees but that is due to her osteoarthritis. She takes ibuprofen 600mg as needed for pain. Ms. Kumar also has an ongoing problem of constipation. She takes OTC bowel cleanses as needed. She states her problem with constipation has gotten worse. She denies any changes to her bowels or abdominal pain. She denies any other health problems other the acid reflux, which is well controlled with esomeprazole 40mg daily. Patient is normally healthy and denies being around anyone sick or any recent travels. Past Medical History Hypertension x20 Years Coronary Artery Disease x8 Years Gastroesophageal Reflux Disease Hypercholesterolemia Coronary Artery Bypass Graft 8 Years Ago G4P Allergies
Psychological: Negative Physical Exam General Survey: Alert, in no acute distress. Height: 5’2” Weight: 122 lbs. Vitals: Temp: 98.2 F, HR: 110, BP: 138/92, RR: 16 Unlabored, O2: 95% Room Air HEENT & Neck: Normocephalic, pupils PERRLA, conjunctival rim pallor, trachea midline, no JVD. Cardiovascular: HR 110, Murmur – Early Systolic Respiratory: Chest is symmetrical, no increase work of breathing. Gastrointestinal/Abdomen: Soft, non-tender, non-distended. Normal bowel sounds. Genitourinary: Did not examine at this time, no complaints per patient. Musculoskeletal: Normal bulk and tone. No Rigidity. Range of motion is equal bilaterally. Neurological: Alert and Oriented x4. CN II through XII is intact. Integumentary (Skin, Hair, Breast): Skin is warm and dry. Palmer crease pallor. Allergic/Immunologic: No Allergies Lymphatic/Endocrine: No Adenopathy Hematologic: No Bruising Psychological: Pleasant Abnormal Labs Hemoglobin: 8.5 g/dl (Normal 14-18 g/dl (♂)) Hematocrit: 25.1% (Normal 42-54% (♂)) Iron: 18 μg/dL (Normal 25 - 170 μg/dL) TIBC: 461 μg/dL (Normal 106 - 364 μg/dL) List of Diagnosis D50.9 Iron Deficiency Anemia Plan Ms. Chana Kumar is diagnosed with iron deficiency anemia. In order to determine the cause, the plan is to obtain a CT of the abdomen to evaluate for colon cancer, colonoscopy, and EGD for her reflux symptoms to rule out esophageal malignancy.