Patient Initials: not identified.
Subjective Data: The patient is a 52-year-old American of Irish descent who presented with an ambiguous complaint of not feeling well.
Chief Complaint: According to the patient, for the last two days, he has experienced “shortness of breath.” (Case Study, n.d., p. 1). The patient also stated that he “has been lightheaded and felt palpitations.” (Case Study, n.d., p. 1).
History of Present Illness: The man reported that the onset of his symptoms started a long time ago. He used to feel palpitations that subsided with rest. However, two days before the visit, when he was performing domestic chores, he felt shortness of breath and palpitations. These symptoms were present during the visit.
PMH/Medical/Surgical History: Hypertension and hyperlipidemia histories—ten years and five years, respectively. A stent placement surgery two weeks before the visit. The patient has been adhering to a low-cholesterol, low-fat diet for two years. Medication history: Gemfibrozil (600 mg), Lisinopril (20 mg), and Furosemide (20 mg). NKDA allergies.
Significant Family History: not identified.
Social History: 15 pack-years of cigarette smoking (20 years). Quit the habit of smoking five years ago.
Review of Symptoms
General: a well-developed man in moderate distress
Integumentary: edema is absent
Head: not identified
Eyes: PERRLA, (-) JVDm with mild AV nicking
ENT: not identified
Cardiovascular: rate is irregularly irregular; gallops and murmurs are absent
Respiratory: CTA
Gastrointestinal: Abd: soft, NT, active bowel sounds
Genitourinary: deferred
Musculoskeletal: not identified
Neurological: A&O X3
Endocrine: not identified
Hematologic: normal pulse rates throughout
Psychologic: not identified
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 with mild AV nicking
Lymph Nodes: not identified
Carotids: not identified
Lungs: clear
Heart: normal
Abdomen: soft, NT
Genital/Pelvic: N/A
Rectum: normal
Extremities/Pulses: edema is absent
Neurologic: A&O X3
Laboratory and Diagnostic Test Results: Na – 136, K – 4.5, and Cl – 1.2 are normal; Total Chol – 240 high risks; trig. 180 high borderline; and INR 1.1 normal.
Assessment
Unspecified atrial fibrillation (I48.91)
Atrial fibrillation can be defined as “a supraventricular tachyarrhythmia with uncoordinated atrial activation and consequently ineffective atrial contraction” (January et al., 2014, p. 12). Symptoms that are most commonly experienced by AF patients are fatigue, dyspnea, and palpitations (Rawles, 2012). Also, ECG shows the presence of atrial fibrillations without P waves (Case Study, n.d.). The presence of these symptoms in combination with the results of the chest X-ray allows making a priority diagnosis of AF.
Supraventricular tachycardia (I47.1)
Supraventricular tachycardia is an episodic event characterized by abnormalities in the heart rate. During the event, the heart rate vacillates between 60 and 160 beats per minute (Link, 2012). Gradual onset of symptoms of the condition usually follows physical exercises. The patient has a “racing” heart and the absence of P waves, which makes it possible to suggest supraventricular tachycardia as a diagnosis (Case Study, n.d., p. 1).
Unspecified heart failure (I50.9).
Heart failure is a condition that results from a structural cardiac disorder and is evident in the impaired ability of the heart to pump blood (Roger, 2013). The condition is a clinical problem that mainly affects people who are aged 65 and older (Roger, 2013; Yancy & Jessup, 2013). Key manifestations of heart failure are dyspnea, heart rate abnormality, and fatigue. Other symptoms are increased venous pressure, edema, atrial fibrillation, and wheezing (Roger, 2013). Taking into consideration the fact that key symptoms are present, it is possible to make a priority diagnosis of heart failure.
Plan of Care
Diagnostic and therapeutic management, as well as education, for three dxs can be combined. However, it has to be borne in mind that medications for each diagnosis still may differ. Diagnostic tests applicable to the case are complete blood count, serial monitoring, a 12-lead ECG, and measurement of BNP (McMurray et al., 2012; Yancy & Jessup, 2013). Regular measurement of BNP will help to reduce the chances of negative outcomes. Therapeutic management revolves around controlling the patient’s heart rate. Taking into consideration the presence of heightened blood pressure, 5mg of Warfarin can be used as pharmacological treatment. Supraventricular tachycardia can be managed with the help of anti-arrhythmic medications (Link, 2012). Meditation and a healthy diet are non-pharmacological types of treatment applicable to this case. In terms of education, the patient should be informed about relevant statistics, the effects of smoking, and the importance of a healthy lifestyle and pharmacological treatment.
References
Case Study. (n.d.).
January, C., Wann, L., Alpert, J., Calkins, H., Cleveland, J., Cigarroa, J.,… Yancy, C. (2014). 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guideline and the Heart Rhythm Society. Circulation, 129(1), 1-124.
Link, M. (2012). Evaluation and initial treatment of supraventricular tachycardia. The New Journal of Medicine, 367(1), 1-15.
McMurray, J., Adamopoulos, S., Anker, S., Auricchio, A., Bohm, M., Dickstein, K.,… Zeiher, A. (2012). ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European Journal of Heart Failure, 14(1), 803-869.
Rawles, J. (2012). Atrial fibrillation. New York, NY: Springer Science & Business Media.
Roger, V. (2013). Epidemiology of heart failure. Circulation Research, 113(6), 646-659.
Yancy, C., & Jessup, M. (2013). 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guideline. Circulation, 128(1), 1-375.