Case Study

Part I: Read the following case study and respond to the questions.  Be sure to provide citation for support of what you answer from either your text or a peer reviewed journal article.

Mr. A.B. is a 40 year old man with a history of idiopathic dilated cardiomyopathy, with NYHA class II symptoms.  He is compliant with his meds, and generally follows his low salt diet and weighs himself regularly.  He arrives for his follow up visit complaining of dyspnea on exertion, 3 pillow orthopnea and ankle edema that he states is worse than his usual baseline.  He is up 5 pounds and admits that at a wedding last weekend, he ate a lot of food he normally does not have.

State in a SOAP format: Subjective, Objective, Assessment and Plan format what you would ask him in terms of history and why?,

what parts of the physical exam would you pay particular attention to and why? and what would your assessment and plan be for Mr. AB?

Cite at least one source.

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