Patient Initials Not Given
Subjective Data: 52-year-old, Irish American Male, 2-miles walks daily, 3-times exercise bicycle weekly
Chief Complaint: lightheadedness, palpitations in the heart, shortness of breath the last two days
History of Present Illness: palpitations associated with the exercises which went away with rest, shortness of breath, and the feeling of his heart being racing while washing dishes two days ago, the palpitations continue till today
PMH/Medical/Surgical History: rheumatic heart disease as a child, a 10-year-old hypertension history, hyperlipidemia for five years, stent placement two weeks ago, a low cholesterol level because of a low-fat diet during the last two years. Lisinopril (20mg), Furosemide (20mg), and Gemfibrozil (600mg). No allergies.
Significant Family History: non-contributory
Social History: 20-year-old history (15 pack/year). Quit five years ago.
Review of Symptoms: (Review each body system – In this section, you should place POSITIVE for… information in the beginning then state Denies…). –
- General: well-developed in moderate distress;
- Integumentary: no edema;
- Head: not given;
- Eyes: PERRLA, (-) JVDm mild AV nicking;
- ENT: not given;
- Cardiovascular: irregular rate, no murmurs or gallops;
- Respiratory: clear to auscultation;
- Gastrointestinal: soft, non-tender, active bowel sounds;
- Genitourinary: deferred;
- Musculoskeletal: not-given;
- Neurological: A&Ox3;
- Endocrine: not-given;
- Hematologic: normal pulses throughout;
- Psychologic: not-given.
Objective Data
Vital Signs: BP – 160/90; P 146; R 22; T 98.6; Wt. 254; Ht. 5’7’’; BMI 9.5.
Physical Assessment Findings: (Includes full head to toe review)
HEENT: PERRLA, JVDm mild AV nicking
Lymph Nodes: –
Carotids: –
Lungs: clear
Heart: normal pulses
Abdomen: soft, non-tender
Genital/Pelvic: Rectum: normal
Extremities/Pulses: no edema
Neurologic: A&Ox3
Laboratory and Diagnostic Test Results: Na – 136, K – 4.5, Cl – 97, BUN – 20, Cr – 1.2, Total Chol. – 240, Trig – 180, INR – 1.1, Chest X-ray – clear, ECG – atrial fibrillation, no P waves, variable R-R interval normal QRS.
In general, the laboratory results are normal and correspond with the norm. Still, the level of cholesterol remains to be high, as well as the level of triglycerides. Such levels are the primary signs of cardiovascular disease, stroke, hypercholesterolemia, and heart attacks.
Assessment
Heart disease, unspecified (ICD-10-CM: I15.9) is a diagnosis that may gain different forms. The patient may have a heart attack regarding such symptoms as shortness of breath, lightheadedness, and chest discomfort when the feeling of the “racing” heart bothered the man. The patient is in the risk group of cardiovascular disease (52 years, smoking history, and high level of cholesterol) (Yang et al., 2015).
Cardiac arrhythmia, unspecified (ICD-10-CM: I49.9) is a disease that is characterized by the presence of heart rhythm problems when the electrical impulses are hard to control because of spontaneous diastolic depolarization (Gaztanaga, Marchlinski, & Betensky, 2012).
Supraventricular tachycardia (ICD-10-CM: I47.1) is the condition when the heart beats too fast, and the heart rate rises causing chest discomfort and other problems like lightheadedness and shortness of breath. The patient’s examination proves a high respiratory rate. Palpitations in his heart are another serious symptom that can be used to prove the diagnosis.
Plan of Care
Three diagnoses offered prove that the patient is under a threat of having a cardiovascular disease that has to be properly diagnosed and treated. The patient should be provided with appropriate therapeutic management, education, and counseling.
Diagnostic management: in all three cases, it is possible to use an event or Holter monitor that aims at recording the heart’s activities and observing heart rhythms regularly. The level of cholesterol should be checked by a regular blood test. Finally, ECG and chest X-ray should be used to prove the progress or inappropriateness of the chosen treatment.
Therapeutic management: Vagal maneuvers are frequently used by doctors to reduce the number of heartbeats. These activities include coughing or holding breath. The nervous system is affected, and the heart rate can be slowed down. Medications can be used in the form of some beta-blockers. Yoga and meditation under the observations of an expert can also help.
Education: The patient should learn about the importance of medication regimes, the necessity to keep diets, and the obligation to never start smoking. It is also necessary to take a physical examination to control changes in eyes, feet, or blood pressure. Finally, a certain portion of control should be devoted to the importance of medications’ change in case no improvements are observed in the next day. The patient should know about the peculiarities of the disease and the role of a healthy lifestyle. The control of cholesterol and blood pressure should not be neglected. No depression or social isolation.
Counseling: If necessary, the patient may address as a psychologist to discuss his main concerns and challenges. Follow-ups with a cardiologist, therapist, and surgeon are possible to get additional consultations and support.
References
Gaztanaga, L., Marchlinski, F.E., & Betensky, B.P. (2012). Mechanisms of cardiac arrhythmias. Revista Espanola de Cardiologia, 65(2). Web.
Yang, Q., Zhong, Y., Ritchey, M., Cobain, M., Gillespie, C., Merritt, R., … Bowman, B.A. (2015). Vital signs: Predicted heart age and racial disparities in heart age among U.S. adults at the state level. Morbidity and Mortality Weekly Report, 64(34), 950-958.