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Here is instructions: please follow Assignment 2 Grading Criteria

Patient Medication Profile Assignment
Analyze the following case. Describe the patient’s status and relevant risk factors for worsening chest pain. Create a plan for the patient and suggest changes to her

therapy. Write appropriate orders required for the patient. Patient called for a checkup and since EMR scheduler showed that she had not been seen for > 2 years, she

was sent a lab slip to have lab work done prior to visit. She presents today with the following C.C.
G.G. (patient): “I’ve been having some chest discomfort since my last visit; I think it’s probably just hearburn but I thought I should get checked.”
History of present illness: G.G. is a fifty-four-year-old female with heart disease; she also has a strong family history of heart disease. She was advised several

times in the past ten years to see a dietitian and to take better care of herself by eating right and entering a smoking cessation and exercise program. She did go to

a dietitian once but failed to comply with any of the other programs. She saw a cardiologist two years ago in Ireland but has not followed up in the United States.

Now, she complains of intermittent chest pain that awakens her from sleep and even occurs when she is at rest or when she is active. No pain during office visit.
Past medical history:
• Hypertension for the past ten years
• Peptic ulcer disease (PUD) two years ago
Family history: Her father died of a myocardial infarction (MI) at the age of forty-seven years; her mother, aged seventy-two, is alive with type 2 diabetes mellitus.

An older brother died two years ago of an MI at the age of fifty-five. She has one younger sister aged forty-three with hypertension and hyperlipidemia and a sister

aged forty-one with depression and no knowledge of her cholesterol levels.
SH: Drinks two or three vodka martinis every day after work and smokes a pack of cigarettes every day.
ROS: (+) For occasional headache in the morning; no chest pain, shortness of breath, abdominal pain, melena, or recent changes in bowel or bladder habits.
• Zestril 10 mg po qAM
• HCTZ 25 mg po qAM
• Occasional Tylenol use p.r.n
• MVI one tablet po qd
Allergy: No known drug allergies
Significant Lab Findings:
• Total Cholesterol……….325mg/dL
• HDL Cholesterol……….40mg/dL
• LDL Cholesterol……….160mg/dL
• Triglycerides……………200mg/dL
• FBS……………………..109mg/dL

General: Patient is an obese female who wears glasses. She is in no acute distress.
Vital Signs: BP: 147/80; P: 76; RR: 13; T: 98.9″F; Ht: 5’5″; Wt: 237.6 lbs.
Skin: Warm and dry, normal turgor, no lesions/tumors/moles
Head, eyes, ears, nose, and throat (HEENT): PERRLA; EOMI; funduscopic exam reveals mild arteriolar narrowing with AV ratio 1:3; no hemorrhages, exudates, or

papilledema (Keith-Wagener-Barker funduscopic class: grade II); TMs intact; oral mucosa clear
Neck/LN: Neck supple with no lymphadenopathy; normal thyroid
Lungs/Thorax: Diffuse wheezing bilaterally
Cardiovascular/PV: Regular rate and rhythm (RRR), no murmurs, normal S1, and S2, no S3, or S4, no lower leg edema
Abdominal (ABD): (+) BS. liver and spleen not palpable
Neuro: A & 0 x 3; reflexes bilaterally equal; memory intact; coordination and gait normal; CN II to XII intact
Provide references with your explanations.
Submit your answers in a Microsoft Word document (maximum of 4 pages).
Cite any sources using the APA format on a separate page.
Assignment 2 Grading Criteria Maximum Points
Identified correctly and described the risk factors and medications contributing to the case. 15
Created an appropriate, committed plan for the patient. 15
Wrote appropriate orders for the patient. 5
Used correct spelling, grammar, and professional vocabulary. Cited all sources using the APA format. 5
Total: 40


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