Cardiovascular Clinical Case and Care Plan

Patient Initials: N. S., a 52-year-old male.

Subjective Data

Chief Complaint: The patient reports vertigo, shortness of breath, and palpitations.

History of Present Illness: Heart palpations associated with exercising are observed for some time, and they cease when resting. Shortness of breath was observed two days ago, but the associated palpations continued to be observed.

PMH/Medical/Surgical History: The patient had rheumatic heart disease when being a child, hypertension for ten years, and hyperlipidemia for five years. The low-fat diet is followed for two years. The stent placement was conducted two weeks ago. He has no drug allergies. The prescribed medications include Lisinopril (20 mg), Furosemide (20 mg), and Gemfibrozil (600 mg).

Significant Family History: Noncontributory.

Social History: The patient reports riding an exercise bicycle three times a week, walking two miles a day, and following a low-fat diet. He smoked regularly in the past and quitted smoking five years ago.

Review of Symptoms

  • Integumentary: denies bruising;
  • HEENT: PERRLA, (-) JVDm mild arteriovenous nicking;
  • Cardiovascular: positive for an irregular rate, no murmurs, gallops;
  • Respiratory: positive for shortness of breath;
  • GI/GU: normal, denies vomiting, nausea;
  • Neurological: AAO X3;
  • Psychological: positive for moderate distress.

Objective Data

Vital Signs: BP 160/90, RR 22, HR 146, T 98.6F, Wt 254, Ht 5’7”, BMI = 39.78.

Physical Assessment Findings

HEENT: PERRLA, (-) JVDm mild arteriovenous nicking;

Lymph Nodes: n/a;

Carotids: n/a;

Lungs: clear to auscultation;

Heart: no edema;

Abdomen: soft, non-tender;

Genital/Pelvic: n/a;

Rectum: normal;

Extremities/Pulses: normal pulses;

Neurologic: AAO X3.

Laboratory and Diagnostic Test Results: K – 4.5, Na – 136, Cl – 97, BUN – 20, Cr – 1.2, Total Cholesterol – 240, Triglycerides – 180, INR – 1.1, Chest Xray – Clear, ECG – Atrial Fibrillation, no P waves. The triglycerides and cholesterol levels are high, resulting in risks of developing heart disease. Atrial fibrillation is typical for such cardiovascular disease as arrhythmia.

Assessment

ICD-10 Diagnoses

ICD-10-CM: I47.1 Supraventricular tachycardia;

ICD-10-CM: I49.9 Cardiac arrhythmia, unspecified;

ICD-10-CM: E663 Overweight.

Plan of Care

Supraventricular tachycardia and cardiac arrhythmia

The diagnostic management should include regular ECG tests, monitoring heart rhythms, measurements of blood pressure, as well as blood tests (Moore, 2014). The therapeutic management should include interventions to reduce palpitations and discomfort while breathing and walking (Moore, 2014). The patient should continue taking Lisinopril (20 mg).

The patient should be educated regarding the risks of high blood pressure and inappropriate high-fat diets to cause complications in persons with a stent and the history of heart diseases (Moore, 2014). The necessity of regular monitoring of blood pressure should be accentuated, and guidelines on using the blood pressure monitor should be provided. It is important to consult a psychologist to receive counseling because of symptoms of distress and a cardiologist to monitor conditions associated with the stent placement.

Overweight

The diagnostic management should include regular blood tests to measure the cholesterol level. The patient should continue taking Gemfibrozil (600mg) and pay more attention to following a low-fat diet (Lu et al., 2014).

The patient should be educated regarding the use of a diary to control his diet and consume more fresh and green vegetables. The consumption of saturated fats and sugars should be highly controlled (Lu et al., 2014). The consultation with a dietician can be beneficial for the patient to select a healthy diet to decrease his weight and cholesterol level (Lu et al., 2014). The follow-up plan should include consultations with a cardiologist every two weeks during two months.

References

Lu, Y., Hajifathalian, K., Ezzati, M., Woodward, M., Rimm, E. B., Danaei, G.,… Van Herck, K. (2014). Metabolic mediators of the effects of body-mass index, overweight, and obesity on coronary heart disease and stroke: A pooled analysis of 97 prospective cohorts with 1.8 million participants. Lancet, 383(9921), 970-983.

Moore, J. P. (2014). Arrhythmia management for the adult patient with congenital heart disease: An update and analytical review. Minerva Pediatrica, 66(5), 415-439.

Calculate the price
Make an order in advance and get the best price
Pages (550 words)
$0.00
*Price with a welcome 15% discount applied.
Pro tip: If you want to save more money and pay the lowest price, you need to set a more extended deadline.
We know how difficult it is to be a student these days. That's why our prices are one of the most affordable on the market, and there are no hidden fees.

Instead, we offer bonuses, discounts, and free services to make your experience outstanding.
How it works
Receive a 100% original paper that will pass Turnitin from a top essay writing service
step 1
Upload your instructions
Fill out the order form and provide paper details. You can even attach screenshots or add additional instructions later. If something is not clear or missing, the writer will contact you for clarification.
Pro service tips
How to get the most out of your experience with Online Academic Experts
One writer throughout the entire course
If you like the writer, you can hire them again. Just copy & paste their ID on the order form ("Preferred Writer's ID" field). This way, your vocabulary will be uniform, and the writer will be aware of your needs.
The same paper from different writers
You can order essay or any other work from two different writers to choose the best one or give another version to a friend. This can be done through the add-on "Same paper from another writer."
Copy of sources used by the writer
Our college essay writers work with ScienceDirect and other databases. They can send you articles or materials used in PDF or through screenshots. Just tick the "Copy of sources" field on the order form.
Testimonials
See why 20k+ students have chosen us as their sole writing assistance provider
Check out the latest reviews and opinions submitted by real customers worldwide and make an informed decision.
Business Studies
Thank you very much for a good job done and a quick turn around time.
Customer 452615, March 31st, 2021
Communications
Thank you so much for your attention to this assignment and timeliness.
Customer 453111, November 12th, 2022
Psychology
quick, fast and exact!
Customer 453027, May 24th, 2022
Criminal Justice
The paper was not accused of plagiarism and was written very well. I will let you know the grade once it is graded. Thank you
Customer 452671, April 26th, 2021
Business and administrative studies
excellent
Customer 453201, October 22nd, 2022
Literature
Thank you!
Customer 453145, April 19th, 2022
Psychology
Great paper, Thank you so much.
Customer 453209, October 4th, 2022
English 101
thank you for the excellent work
Customer 452883, October 29th, 2021
Business and administrative studies
excellent
Customer 453201, November 21st, 2022
Criminal Justice
This has been the greatest help while I am recovering from an illness. Thank your team so much.
Customer 452671, May 2nd, 2021
Management
It's the second time I use this service and it does not let me down. Work quality is so good for its price!
Customer 452985, December 3rd, 2021
Sociology
THANK YOUUUUU
Customer 452591, March 18th, 2021
11,595
Customer reviews in total
96%
Current satisfaction rate
3 pages
Average paper length
37%
Customers referred by a friend
OUR GIFT TO YOU
15% OFF your first order
Use a coupon FIRST15 and enjoy expert help with any task at the most affordable price.
Claim my 15% OFF Order in Chat
Live ChatWhatsApp