2023 Nursing WEEK 12: SOAP FORM PLEASE. DISCUSSION QUESTION IN DISCUSSION BOARD CARDIOVASCULAR CASE STUDY
Chief complaint medication refill I ran out of medicines HPI E D a 65 year old AA male presents to the clinic 2023
Chief complaint: medication refill ” I ran out of medicines”
HPI: E.D a 65-year-old AA male presents to the clinic for prescription refills. The patient also indicates that she has noticed shortness of breath which started about 4 months ago. The SOB gets worse with exertion, especially when she is walking fast and it is resolved when he is resting. He reports that she is also bothered by shortness of breath that wakes her up intermittently during her sleep. His symptoms of shortness of breath resolve after sitting upright on 3 pillows. He also has lower leg edema pitting 1+ which started 2 weeks ago. He also indicates that she often feels light headed at times with intermittent syncope episodes while going up a flight stairs, but it resolves after sitting down to rest. He has not tried any over the counter medications at home.
He never filled her prescriptions that he received at her checkup 6 months ago, she did not think it was important.
PMH:
Primary Hypertension
Previous history of MI 1 year ago
Surgeries:
1 year ago-Left Anterior Descending (LAD) cardiac stent placement
Allergies: Penicillin
Vaccination History:
He receives an annual flu shot. Last flu shot was this year
Has not had a Td in over 10 years
Has not had the herpes zoster vaccine
Social history:
High school graduate, married and no children. He drinks one 4-ounce glass of red wine daily. He is a former smoker that stopped 3 years ago.
Family history:
Both parents are alive. Father has history of MI and valvular heart disease; mother alive and cardiac history is unknown. He has one brother who is alive and has history of MI 5 years ago at age 52.
ROS:
Constitutional: Lightheaded and faint with exertion.
Respiratory: Shortness of breath with exertion. + Orthopnea
Cardiovascular: + 2 pitting leg edema for 3 weeks.
Psychiatric: Pt sated not taking medications for 6 months – “ran out and did not get refills”
Physical examination:
Vital Signs
Height: 5 feet 1 inches Weight: 163 pounds BMI: 31 obesity, BP 157/87 T 98.0 po P 110 R 22, non-labored
HEENT: Normocephalic/Atraumatic, Bilateral cataracts; PERRL, EOMI; No teeth loss seen. Gums no redness.
NECK: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.
LUNGS: + Mild Crackles on inspiratory phase no clearing with cough. Equal breath sounds. Symmetrical respiration. No respiratory distress.
HEART: Normal S1 with S2 during expiration. An S4 is noted at the apex; + systolic murmur noted at the right upper sternal border without radiation to the carotids. Pulses are 2+ in upper extremities and 2+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally
ABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.
GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred.
MUSCULOSKELETAL: + Heberden’s nodes at the DIP joints, hands. + Crepitus, bilateral knees. Slow gait but steady. No Kyphosis.
PSYCH: Normal affect. Cooperative.
SKIN: No rashes. + Dry skin. Skin intact.
Labs:: Hgb 13.2, Hct 38%, K+ 4.0, Na+137, Cholesterol 225, Triglycerides 187, HDL 37, LDL 190, TSH 3.7, glucose 98
A:
Primary Diagnosis:
Congestive Heart Failure (CHF) (150.9)
Secondary Diagnoses:
Primary Hypertension (I10)
Obesity (E66):
Osteoarthritis (OA) (715.90)
Differential Diagnosis:
Peripheral Vascular Disease (PVD) (173.9)
P:
Medications:
Tylenol 650 mg PO Q4 hours as needed for arthritis pain
Labs: UA; Brain natriuretic peptide (BNP); LFTs and TSH.
12-lead EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-brachial index
Referrals: may refer based on lab results
Follow up: return to office in 2 weeks
Additional lab results:
Echo results 1 week ago: Left ventricular EJ Fraction decreased to 30 %
BNP – no available
Questions: As an NP student, need to determine the medications for CHF/ASCVD
According to the ACC/AHA Guidelines, what medications should this patient be prescribed? Does he need medication given his history of MI? Write her complete prescriptions using the prescription writing format.
answer: please use this medication
I suggest an ACE inhibitor for this patient and not the above medications.
I would start Lisinopril 5 mg po daily and lasix 20 mg po daily and potassium supplement 10 meq po daily.
I would consider Xopenex 0.63 % use in inhaler nebulizer treatment every 4 to 6 hours as needed.
Please tell me why ?
