Cardiovascular Clinical Case and Care Plan

Patient Initials: N. S., a 52-year-old male.

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Subjective Data

Chief Complaint: The patient reports vertigo, shortness of breath, and palpitations.

History of Present Illness: Heart palpations associated with exercising are observed for some time, and they cease when resting. Shortness of breath was observed two days ago, but the associated palpations continued to be observed.

PMH/Medical/Surgical History: The patient had rheumatic heart disease when being a child, hypertension for ten years, and hyperlipidemia for five years. The low-fat diet is followed for two years. The stent placement was conducted two weeks ago. He has no drug allergies. The prescribed medications include Lisinopril (20 mg), Furosemide (20 mg), and Gemfibrozil (600 mg).

Significant Family History: Noncontributory.

Social History: The patient reports riding an exercise bicycle three times a week, walking two miles a day, and following a low-fat diet. He smoked regularly in the past and quitted smoking five years ago.

Review of Symptoms

  • Integumentary: denies bruising;
  • HEENT: PERRLA, (-) JVDm mild arteriovenous nicking;
  • Cardiovascular: positive for an irregular rate, no murmurs, gallops;
  • Respiratory: positive for shortness of breath;
  • GI/GU: normal, denies vomiting, nausea;
  • Neurological: AAO X3;
  • Psychological: positive for moderate distress.

Objective Data

Vital Signs: BP 160/90, RR 22, HR 146, T 98.6F, Wt 254, Ht 5’7”, BMI = 39.78.

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Physical Assessment Findings

HEENT: PERRLA, (-) JVDm mild arteriovenous nicking;

Lymph Nodes: n/a;

Carotids: n/a;

Lungs: clear to auscultation;

Heart: no edema;

Abdomen: soft, non-tender;

Genital/Pelvic: n/a;

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Rectum: normal;

Extremities/Pulses: normal pulses;

Neurologic: AAO X3.

Laboratory and Diagnostic Test Results: K – 4.5, Na – 136, Cl – 97, BUN – 20, Cr – 1.2, Total Cholesterol – 240, Triglycerides – 180, INR – 1.1, Chest Xray – Clear, ECG – Atrial Fibrillation, no P waves. The triglycerides and cholesterol levels are high, resulting in risks of developing heart disease. Atrial fibrillation is typical for such cardiovascular disease as arrhythmia.


ICD-10 Diagnoses

ICD-10-CM: I47.1 Supraventricular tachycardia;

ICD-10-CM: I49.9 Cardiac arrhythmia, unspecified;

ICD-10-CM: E663 Overweight.

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Plan of Care

Supraventricular tachycardia and cardiac arrhythmia

The diagnostic management should include regular ECG tests, monitoring heart rhythms, measurements of blood pressure, as well as blood tests (Moore, 2014). The therapeutic management should include interventions to reduce palpitations and discomfort while breathing and walking (Moore, 2014). The patient should continue taking Lisinopril (20 mg).

The patient should be educated regarding the risks of high blood pressure and inappropriate high-fat diets to cause complications in persons with a stent and the history of heart diseases (Moore, 2014). The necessity of regular monitoring of blood pressure should be accentuated, and guidelines on using the blood pressure monitor should be provided. It is important to consult a psychologist to receive counseling because of symptoms of distress and a cardiologist to monitor conditions associated with the stent placement.


The diagnostic management should include regular blood tests to measure the cholesterol level. The patient should continue taking Gemfibrozil (600mg) and pay more attention to following a low-fat diet (Lu et al., 2014).

The patient should be educated regarding the use of a diary to control his diet and consume more fresh and green vegetables. The consumption of saturated fats and sugars should be highly controlled (Lu et al., 2014). The consultation with a dietician can be beneficial for the patient to select a healthy diet to decrease his weight and cholesterol level (Lu et al., 2014). The follow-up plan should include consultations with a cardiologist every two weeks during two months.


Lu, Y., Hajifathalian, K., Ezzati, M., Woodward, M., Rimm, E. B., Danaei, G.,… Van Herck, K. (2014). Metabolic mediators of the effects of body-mass index, overweight, and obesity on coronary heart disease and stroke: A pooled analysis of 97 prospective cohorts with 1.8 million participants. Lancet, 383(9921), 970-983.

Moore, J. P. (2014). Arrhythmia management for the adult patient with congenital heart disease: An update and analytical review. Minerva Pediatrica, 66(5), 415-439.

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