Health Assessment: Identifying Data- Pulmonary Arterial Hypertension

Identifying Data
The patient is a pleasant 44 y/o AA female in clinic for SOB due to known history of pulmonary hypertension. Patient admits that she was diagnosed 2 years ago. Patient states “the pulmonary hypertension is getting worse, I am on oxygen for exertion and sleep.” You are the new nurse practitioner working in a cardiology practice. The patient was referred to you by her pulmonologist for cardiac evaluation.
Medical Diagnosis: Pulmonary Arterial Hypertension (416.0)
Subjective Data:
C/C: Dyspnea
PMH: bronchitis, primary pulmonary hypertension
Hospitalization: Chest pain 5 years ago
PSH: C-section
FMH: Mother with HTN, father with DM
Social: denies smoking, alcohol use
Sexual activity: has one partner
Immunization: up to date
Meds: Oxygen, Multivitamin
Allergy: NKDA
Last PE: 2 weeks ago
Objective Data:
VS: HR 85, BP 135/72, RR 20, T 98.0, O2 sat 93 RA
EKG: normal sinus rhythm, right ventricular hypertrophy
Notes from Pulmonologist:
Notes from Pulmonary MD
Chest X-ray: pulmonary artery dilation
Sleep studies: moderate desaturation during the night.
PFT: findings are at the lower limits of normal.
Echocardiogram from 2 years ago: Pulmonary hypertension
MRI: Enlargement of right ventricle
V/Q scan: negative for pulmonary embolism
Requirements:
Please write a complete head to toe soap notes in a Power Point format, covering all basis including:
Subjective data, Objective data, Differential diagnosis, Consultation/referral, Follow up, Your role as a nurse practitioner treating this disease, Health disparity, genetic & genomics considerations, Collaboration issues. Anticipated Cost of Care, and Health promotion

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