The First Case’s Discharge Summary Report
Admitting Diagnosis
The symptoms that the patient has currently can be attributed to a variety of diseases. The fact that the patient has been experiencing changes in the heart rhythm (particularly, tachycardia) points to the possibility of having a heart rhythm disorder (HRD). The signs of dizziness shown by the patient also indicate that the HRD is most likely to be the problem. However, it could also be argued that the patient has been suffering from anxiety disorder (AD). Being affected by specific factors at the identified point in time, she may have experienced an instance of AD.
Discharge Diagnosis
The fact that the patient had been taking Levoxyl, along with the rest of the symptoms, showed that the HRD was the key diagnosis and the primary issue that had to be addressed. The patient underwent a treatment program aimed at managing the HRD issue. Particularly, Levoxyl was replaced with its natural substitute, desiccated thyroid. As a result, the threat of developing further heart issues was removed (Tran and Hua 3).
Procedures
The patient was provided with extensive information on identifying the instances of HRD, as well as the information concerning the location of the essential symptoms and the facilities that can provide the required services in a timely and efficient manner. Furthermore, the necessary measurements, including the pulse rate, regularity, and amplitude were made. Thus, the emergent risks were identified and prevented successfully. Additionally, the heart sounds were measured to identify the nature of the problem and determine the degree to which it has evolved (Tracy et al. par. 23).
Consultations
The patient was provided with extensive consultations on the nature of the disease, the factors that promote and inhibit it, and the means of managing the disorder. Specifically, the dangers of loud and threatening environments were detailed to the patient, with the emphasis on the significance of a calm and comforting setting. The patient was also instructed on the ways of contacting the nursing experts in case of an instance of HRD. Finally, the importance of family support was explained to both the patient and her spouse.
Complications
Unless the treatment is provided in a timely and efficient manner and the patient follows the recommendations of the nursing staff fully, the instance of heart failure may become a possibility.
Physical Examination
Taking the patient’s pulse and subjecting them to the EKG or the ECG procedure were the primary examination steps.
- General: The patient shows generally positive signs.
- Vital Signs: The pulse rate of the patient was 101 beats per minute, the respiration rate made 20 breaths per minute, the body temperature was 97.5° F, the pulse is 80, and the blood pressure was 146/86.
- Heent: No negative data.
- Neck: No negative data.
- Chest: Mild chest pain.
- Heart: Increased heart rate.
- Abdomen: No negative data.
- Extremities: No negative data.
- Neurologic: The patient complained about headaches.
Findings
The patient was suffering from an HRD. The change of thyroid medications along with the creation of a more relaxed atmosphere was used as the means of addressing the problem.
Hospital Course
The patient will receive the necessary medical treatment (Tylenol).
Discharge Medications
- acetaminophen (Tylenol)
- ibuprofen (Kaye, Kaye, and Lofton 527)
Discharge Plan & Instructions
The patient must realize that there is a strong need for her to maintain a calm and relaxed attitude. Stressful situations or any other factors that cause an increase in the heartbeat are to be avoided at all costs.
The Second Case’s Discharge Summary Report
Admitting Diagnosis
Based on the signs and symptoms that the patient shows, two possible diagnoses can be determined. First, the patient is likely to suffer from congestive heart failure (CHF). The fact that the patient suffers from chest pains and has an intermittent SVT point to the likeability of the diagnosis to be true. Alternatively, the patient may have developed a Coronary Artery Disease (CAD). Seeing that the latter also manifests itself in tachycardia and high blood pressure rates, the possibility of the disorder to be the cause of the health issues is very high (Shah et al. 1615).
Discharge Diagnosis
CHF and CAD are the most likely problems that the patient may be experiencing at the moment. Therefore, the identified issues should be viewed as the key discharge diagnoses. It should be borne in mind, though, that a range of disorders manifests themselves in the form of dyspnea; therefore, the patient must be under consistent observation so that other symptoms could be located at the earliest stages of the problem development, and that the issue could be addressed promptly.
Procedures
The patient was given a plethora of information on the heart issues and the means of locating the symptoms, as well as contacting the corresponding nursing services. Additionally, the patient was submitted to an EKG and an ECG so that the problem could be determined more accurately.
Consultations
Nursing consultations on the matter of locating the resources related to the dyspnea issues, including the relevant information (printed and online data sources), the means of contacting the nearby nursing facilities, etc. were provided to the patient.
Complications
The patient may develop complications such as respiratory failure and heart failure.
Physical Examination
ECG and EKG should be viewed as the essential examinations to subject the patient to (National Heart, Lung, and Blood Institute “How Is Heart Disease Diagnosed?” par. 2).
- General: The current state of the patient requires consistent supervision.
- Vital Signs: The pulse rate of the patient was 76 beats per minute, the respiration rate made 25 breaths per minute, the body temperature was 98.2° F, and the blood pressure was 160/98.
- Heent: Normocephalic.
- Neck: Neck veins.
- Chest: Scattered rhonchi, cough (occasional).
- Heart: Tachycardia.
- Abdomen: Swelling.
- Extremities: Minor swelling.
- Neurologic: Anxiety and sleep disorder.
Findings
The patient is likely to suffer from CHF and CAD.
Hospital Course
The patient will be subjected to regular EKGs and ECGs. Furthermore, the necessary medical treatment will be provided (National Heart, Lung, and Blood Institute “How Is Heart Disease Treated?” par. 3).
Discharge Medications
- Lanoxin
- Apresoline
Discharge Plan & Instructions
The patient should take his medicine regularly. Additionally, the factors that cause distress are to be avoided. A calm and relaxed environment is recommended.
Works Cited
Kaye, Adam M., Alan D. Kaye, and Elise C. Lofton. “Basic Concepts in Opioid Prescribing and Current Concepts of Opioid-Mediated Effects on Driving.” The Ochsner Journal 13.4 (2013): 525–532. Print.
National Heart, Lung, and Blood Institute. How Is Heart Disease Diagnosed? 2015. Web.
National Heart, Lung, and Blood Institute. How Is Heart Disease Treated? 2015. Web.
Shah, Amee, Anita Moon-Grady, Neil Bhogal, and Kathryn K. Collins. “Effectiveness of Sotalol as First-Line Therapy for Fetal Supraventricular Tachyarrhythmias.” American Journal of Cardiology 109.11 (2012): 1614-1618. Print.
Tracy, Cynthia M., Andrew E. Epstein, Dawood Darbar, John P. DiMarco, Sandra B. Dunbar, and Mark Estes. 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. 2012. Web.
Tran, Jessica, and Len Hua. 100 Commonly Prescribed Drugs. 2013.