Subjective
Chief complaint: A 77-year-old white male with a chief complaint of “feeling dizzy, short of breath, easily fatigued, and having a sensation of his heart skipping beats”
History of present illness: The patient relates the discomfort for the past 3 days, however symptomatic previously for the last year on a one-day basis.
Delegate your assignment to our experts and they will do the rest.
Medical history: Diagnosed with type 2 diabetes twenty years ago and hypertension fifteen years ago.
Medication: Lisinopril 20 mg daily and Metformin 1000 mg daily.
Objective
Vitals: BP 172/100,
Pulse: 123 irregularly irregular,
R 20
Physical examination finding: The skin is warm and pale with a slight gray cast. The lungs appear clear to auscultation and the heart has an irregular rhythm.
Assessment
Problem: the chief complainant experiences an irregular heartbeat posing as his recurring symptom.
Differential diagnosis: from the symptoms observed the patient having a history of type 2 diabetes and hypertension, the possible diagnosis for the patient could be congestive heart failure (‘symptom checker’, n.d).
Plan
Therapeutics
The basic goal of treatment for heart failure is improving the functional capacity and quality of life to increase mortality and reduce hospital hours. For the non-pharmacological intervention physical exercise has not only proven to be safe to the patients but also helps in psychological benefits (Ioana, 2018). For pharmacological intervention, the use of intravenous iron, ivabradine, diuretics, vasodilators, anticoagulants, and Trimetazidine, increases the exercise capacity in heart failure patients.
Educational
For starters, weight monitoring should be observed with keen every day. The next teaching thought to the patient is to observe their discharge medication. The next area is to focus on improving the activity level to boost their immunity. Another key area is on a diet where the patient should avoid fatty foods and alcoholic drinks. The patient should then be aware of any symptoms that might show worsening of his problem. For instance, he should be able to check increases in edema, shortness of breath, and weight (Denise &Benbow, 2009). Finally, follow-up appointments are to be kept.
Consultation/collaboration
The patient can be enrolled in the hospital's physical therapy as a start and with time he can be referred to a cardiac rehabilitation program, where the staff of the program can provide a safe place to start exercising and also post-discharge education and referral ( Seferović, 2017) .
References
Denise, A., & Benbow. (2009, September). Heart failure: Educating your patient can help prevent readmission. Retrieved from https://www.nursingcenter.com/journalarticle?Article_ID=940643&Journal_ID=54013&Issue_ID=940640
Ioana Dumitru. (2018, May 7). Heart Failure Treatment & Management: Approach Considerations, Nonpharmacologic Therapy, Pharmacologic Therapy. Retrieved from https://emedicine.medscape.com/article/163062-treatment
Seferović, P. M. (2017). ESC/HFA Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2016. Journal of Cardiac Failure , 23 (10), S7. doi: 10.1016/j.cardfail.2017.08.005
Symptom Checker from WebMD. Check Your Medical Symptoms. (n.d). Retrieved from https://symptoms.webmd.com/default.htm#/conditions
