The comprehensive physical examination is expected to indicate JVP-5cm at 45 degrees on HEENT assessment, normal split of the S1, S2, S3, and S4, with a regular heart rhythm and no murmur on the cardiac, bilateral crackles with vesicular breath sounds on lung examination, non-tender and soft abdomen with audible bowel sounds, 2+ distal pulses bilaterally on assessment of the peripherals, and 2+ pitting edema bilateral on assessment of his extremities. This examination is supported by the patient’s history of systolic heart failure, and diabetes. In addition, these signs support heart failure, acute interstitial pneumonitis, and pulmonary hypertension as the additional differential diagnoses.
The medications are appropriate for the patient. However, Angiotensin-converting enzyme (ACE) inhibitors is missing as a critical drug to address the systolic heart failure. The drug serves as a vasodilator, and expands the blood vessels to reduce blood pressure (Mayo Clinic, 2017). The drug also reduces the workload of the heart by improving blood flow. In addition, digoxin can be recommended to increase strength of his heart muscles. The drug is suitable for a person with a heart rhythm problem, for example atrial fibrillation (Mayo Clinic, 2017). In addition, physical therapy should be considered for this patient to manage his increasing weight. Physical exercise promotes energy balance in the body, therefore enabling the body to appropriately accomplish the process of homeostasis (Cox, 2017).
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The key safety considerations are to ensure that no diagnostic errors or medical errors are made during patient treatment. For example, care should be taken to make sure that the patient is prescribed and given the correct drugs, and this can be managed by ensuring that the facility coordinate safety efforts through its medical safety officer. The missing order for this patient is Angiotensin-converting enzyme (ACE) inhibitors and digoxin.
References
Cox, C. E. (2017). Role of physical activity for weight loss and weight maintenance. Diabetes
Spectrum , 30 (3), 157-160.
Mayo Clinic. (2017). Heart failure.
https://www.mayoclinic.org/diseases-conditions/heart-failure/diagnosis-treatment/drc-20373148
