Subjective Data
Chief Complaint (CC):
- Shortness of breath when lying down
- Fatigue
- Sudden weight gain
- Chest pain
History of Present Illness (HPI):
The patient experiences a strong pain in the chest and shortness of breath when lying down. DJ has a bad sleeping pattern, and no remitting factors were found.
Medications
120 mg orally (daily, three times a day), only together with fat-containing food. May be taken throughout the mealtime or within one hr. of finishing the meal.
Medication Intolerances
DJ has no medication intolerances.
Past Medical History (PMH)
- Allergies (Drugs, Food, and Environmental):
- The patient does not have any allergies.
- Tobacco, alcohol, or illicit drug use in the past:
- DJ has been a smoker for the last 30 years.
- Chronic Illnesses/Major traumas:
- The patient is not exposed to any chronic illnesses.
- History of any illness:
- Childhood: measles, chickenpox
- Adult: obesity
- Ob/Gyn: none
- Psychiatric: none
- Hospitalizations/Surgeries:
- DJ was hospitalized several times due to diabetes and suspected heart failure.
Family History
The patient’s father was diagnosed with chronic heart disease. His grandmother had diabetes. Predisposition to obesity was found in all of DJ’s parents.
Social History
DJ received a degree in engineering and worked as a foreman. He is currently married. Started smoking 30 years ago. The home conditions are adequate. Also, there are rugs on the floor and sufficient lighting.
ROS
General
Weight change, fatigue, swelling in legs, inability to exercise.
Cardiovascular
Chest pain, palpitations, irregular heartbeat.
Skin
There are no deviations from the norm.
Respiratory
Cough.
Eyes
DJ wears glasses.
Gastrointestinal
–
Ears
Slight hearing loss.
Genitourinary/Gynecological
Insignificant urinary complaints.
Nose/Mouth/Throat
–
Musculoskeletal
Back pain, joint swelling.
Breast
–
Neurological
Weakness, fatigue.
Heme/Lymph/Endo
No deviations were identified.
Psychiatric
Spoiled sleeping pattern
Objective Data
- Weight 272
- BMI 36.9
- Temp 97.7
- BP 145/90
- Height 6’0”
- Pulse 168 bpm
- Resp –
General Appearance
Healthily appearing elderly individual. Was actively involved in the assessment and answered the questions on time.
Skin
Skin is brown, warm, dry, clean, and undamaged. No eruptions or lacerations identified.
HEENT
- Head: is normocephalic, atraumatic, and without lacerations; hair evenly distributed.
- Eyes: undamaged EOMs.
- Ears: positive light reflex; easily identified landmarks.
- Nose: No septal deviation.
- Neck: Flexible, no cervical lymphadenopathy. Oral mucosa is pink and saturated. The pharynx is nonerythematous and without exudate.
- Teeth: in good repair.
Cardiovascular
Third heart sound
Respiratory
Lungs clear to auscultation bilaterally.
Gastrointestinal
Abdomen obese; Abdomen soft, non-tender.
Breast
–
Genitourinary
–
Musculoskeletal
Full ROM has been seen in all four extremities as the patient moved about the exam room.
Neurological
No issues with speech and posture.
Psychiatric
Watchful and oriented, neatly dressed. Provides appropriate answers to the questions, speaks clearly, and can maintain sufficient eye contact.
Lab Tests
- MRI – pending
- CT – pending
- Special Tests
Differential Diagnoses and Diagnosis
Differential Diagnoses
- Pulmonary edema
- Cardiac cirrhosis
- Fatigue/ Decreased cardiac output
Final Diagnosis
Heart failure
Plan/Therapeutics
Plan
Further testing
I would recommend DJ to pass a chest X-ray exam to see the disorders present in the patient’s lungs and heart (Lam, Donal, Kraigher-Krainer, & Vasan, 2011). There is also a possibility to pass a stress test to see how the patient’s heart will respond to exertion. A coronary angiogram is one of the most significant tests that can be performed (Lam et al., 2011). This test will help me to identify if there are any narrowed arteries close to DJ’s heart.
Medication
I would prescribe beta-blockers (Coreg or Zebeta) and ACE inhibitors (Vasotec). This would help DJ to live longer, reduce blood pressure, and reverse some of the adverse effects on the heart.
Education
The patient should be aware of the ways decreased cardiac input would impact his life. The nurse should inform DJ about the changes in the lifestyle necessary to make the treatment efficient (Lam et al., 2011). The patient has to be informed about the treatment plan and possible outcomes of the proposed interventions. An adequate dialogue between DJ and the nurse is critically important.
Non-medication treatments
I would recommend introducing a diet (Roger, 2013). The food should contain no fat and salt. Due to the rapid weight gain, I would also recommend condensing the intake of fluids (Roger, 2013). DJ should also gradually quit smoking or at least try to avoid it. The nurse should also encourage regular exercise. I would also ensure that DJ is socially active and do everything to prevent the patient’s social isolation (Roger, 2013). The nurse will also recommend reducing physical capacity if DJ decides to come back to work or perform any physical activity.
When should the patient return to the clinic?
I would hospitalize DJ when he has an outburst of heart failure warning signs. While in the hospital, DJ might receive necessary medications that would help his heart to stabilize and mitigate the adverse effects of the illness (Roger, 2013).
Evaluation of patient encounter
The patient is aware of his health problem and acts adequately. DJ wants to be involved in the treatment and believes that it is necessary to deal with the illness as soon as possible. The overall assessment of the patient helped me to identify that there are no critical issues except probable heart failure. In general, I would characterize the current patient encounter as professional and courteous. DJ answered questions promptly and showed a great level of concentration throughout the appointment and examination. As far as I am concerned, my main weakness was the insufficient data regarding DJ’s health history. Despite his responsive approach and extensive evidence, the information that was available to me was not enough. Nonetheless, the key strength consisted of the physical examination and additional tests that would help me to identify the illness and design an appropriate treatment plan. As I grow as a nurse practitioner, I would strive to take into consideration more theoretical aspects. This would assist me greatly in making primary diagnoses, detecting critical warning signs of the illnesses, and navigating better among similar symptoms and diagnoses.
References
Lam, C., Donal, E., Kraigher-Krainer, E., & Vasan, R. (2011). Epidemiology and clinical course of heart failure with preserved ejection fraction. European Journal of Heart Failure,13(1), 18-28.
Roger, V. L. (2013). Epidemiology of heart failure. Circulation Research,113(6), 646-659.