Case Study

Mr. Fitts, a 72-year-old male whose wife died six months ago, is brought to the health care provider by his daughter because he is not eating much and has been lethargic and sleeping a lot. He has a history of hyperlipidemia for which he takes niacin/lovastatin 500/20 mg PO daily at bedtime.

Subjective Data

Has been unusually tired for the past couple of months

Is frequently short of breath and sometimes feels like his ‘heart is pounding’

Has lost weight because his wife always used to cook for him and he doesn’t cook for himself

Describes a typical daily meal as coffee and a donut for breakfast, a hot dog and lemonade for lunch, and a jelly sandwich on white bread and coffee for supper

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Objective Data

Physical Examination

Blood pressure 118/72, pulse 98, temperature 98.2° F, respirations 16

Oxygen saturation 92% on room air

Height 5’6”, weight 135 lbs, BMI 21.7 kg/m2

S1 and S2 auscultated and regular

Bilateral radial pulses +3 and regular

Lungs clear bilaterally