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Case Study

S.P. is a 75-year-old woman who presents to the providers 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

Writing Prompts

1. What other questions should the nurse ask about the fatigue?
2. What other assessments are necessary for this patient?
3. What are some causes of fatigue?
4. Develop a problems list from the objective and subjective data.
5. What should be included in the plan of care?
6. Based on the readings, what is the most likely cause of fatigue for this patient?

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