NR 579 iHuman Week 3 iHuman HPI: Asher Wilson 74 y/o M, Exams of Nursing

Download NR 579 iHuman Week 3 iHuman HPI: Asher Wilson 74 y/o M and more Exams Nursing in PDF only on Docsity! NR 579 iHuman Week 3 iHuman HPI: Asher Wilson 74 y/o M HPI: Asher Wilson 74 y/o M Has had the flu shot Good Questions: How can I help you today?  I haven’t been feeling up to par lately; perhaps all together for 2 or 3 months, now. I’m fatigued and I have no physical energy. I figured it was time to have it checked out. Do you have any other symptoms or concerns we should discuss?  I get short of breath every time I walk even a short distance or climb as few as 10 stairs. I have to stop and rest and catch my breath. I’ve also had a dry cough when I lie down in bed—but that’s only been since I had a cold 3 weeks ago. Have you been having fevers?  Not now. Maybe a low-grade temperature with the cold a few weeks back, but not chills. Have you noticed any swelling in any part of your body?  A year ago, by the end of the day there was definite puffiness of my ankles and shins, and sometimes in my feet, but it typically resolved overnight. But it’s definitely worse and doesn’t seem to get better by the morning. Other than that, no other swelling. Do you sleep with pillows to help you breath?  Yes. I use 3 and sometimes that isn’t enough so I get up to sleep in the recliner. Can you tell me about any current or past medical problems you have had?  I’m in reasonable health for a fellow my age. I’ve been treated for high blood pressure over the last, say 6 or 7 years. And I was checked out for chest pain during that same time. They said I have CAD, but fortunately it never progressed to me needing any intervention. In fact, I only rarely have chest pain. And to be thorough, I should add that I have what they call “wear and tear” arthritis of my neck, and also an old man’s prostate-neither getting any worse; just annoyances. Are you taking any prescription medications? Do you have a dizziness problem?  No Has there been any change in your shortness of breath over time?  Yes. It’s gotten worse. What are the events surrounding the start of your SOB?  There is no event I can specifically point to What symptom is the most distressing for you?  That my energy level is so low; it’s difficult to do even the things I enjoy. And the fact that my breathing troubles are more frequent and more severe. How severe is your shortness of breath?  It is pretty severe, I have not been able to do any work. Do you have pain anywhere? If so, where?  Just arthritis pain in my neck, not a particularly major concern. When did your fatigue/tiredness start?  About 2 to 3 months ago. What are the events surrounding the start of your fatigue/tiredness?  Not sure that there was anything in particular. Does anything make your fatigue/tiredness better or worse?  I don’t really know how to answer that to be honest with you. Maybe if I got better sleep at night? Has there been any change in your fatigue/tiredness over time?  I’m not sure. Maybe it’s just that I’m just more conscious of not feeling well. Do you have night sweats?  Uh..no Does anything make your swelling problem better or worse?  Oh, I suppose if I keep my legs elevated the fluid doesn’t accumulate as much Have you gained or lost weight unintentionally, despite normal appetite and exercise?  Well, I’m not sure anything is really normal right now, but I have put on some weight? How much weight have you gained?  About 15 pounds. Does anything make your difficulty breathing better or worse?  It’s not difficulty breathing. I’m short of breath. Does your difficulty breathing keep you from sleeping?  It’s not difficulty breathing. I’m short of breath. Do you have a cough?  Yes. I have a dry cough that won’t go away. When did your cough start?  About 3 weeks ago when I got that cold. Does anything make your cough better or worse?  Not really. Are you coughing up any sputum?  No, nothing at all. The cough is very dry. Do you have any pain in your chest?  With this breathing thing? No, I wouldn’t say that exactly. Certainly nothing at this exact moment. Any previous medical, surgical or dental procedures?  Nothing of note. I broke the smaller of the 2 bones in my right lower leg playing soccer when I was a teen. And on a separate occasion I broke my forearm playing football. Pretty good for a guy my age to get away without any big medical stuff. Have you ever been hospitalized?  Never, actually. When was your last physical?  I don’t remember Tell me about the health of y our grandparents, parents and children.  My parents of course are long ago passed away, my father passed away due to pneumonia and my mother due to a stroke. My 2 adult sons are very much alive and well. I do not know anything about my grandparents health. Do you ever have withdrawal symptoms if you don’t drink for a day or two? Feeling shaky or jittery?  Nope. Are you eating a lot of salty food?  No. ROS:  Fatigue/difficulty sleeping/unintentional weight loss or gain, fevers, or night sweats?  Do you have any problems with an itchy scalp, skin changes, moles, thinning hair, or brittle nails?  Have you noticed any breast discharge, lumps, scaly nipples, pain, swelling, or redness?  Do you experience chest pain discomfort or pressure; pain/pressure/dizziness with exertion or getting angry; palpitations; decreased exercise tolerance; or blue/cold fingers and toes?  Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, or sputum production? Have you noticed any bruising, bleeding gums, nose bleeds, or other sites of increased bleeding?  No. I’m not on that horrible Coumadin some of my friends are on. Thank the Lord for that! Do you become more weak or tired with exertion?  Yes--both HPI: 74 y/o male presents to the office today with a chief complaint of fatigue and loss of physical energy over the last 2-3 months. Patient reports that he is experiencing associated SOB related to minimal exertion. Patient states persistent dry cough following a recent cold 3 weeks ago. Admits to having episodes of lower leg swelling, primarily at night time, and cannot lay flat due to SOB. ROS Reports decreased appetite, loss of energy, weight gain (approx. 15 lbs), and fatigue. Denies fevers, chills, polyuria, or recent surgery/trauma. Denies sore throat, nasal congestion/drainage, or ear pain. Reports palpitations, lower extremity swelling, and decreased exercise tolerance. Denies chest pain/pressure or dizziness. Reports orthopnea and dyspnea on exertion (3 pillows). Denies wheezing, productive cough, and hemoptysis. Inspect mouth/pharynx: No hoarseness. Oropharynx not injected, clear mucosa, tonsils, without Visual inspection-anterior & posterior chest: Atraumatic thorax. Normal A-P diameter. No use of Drinks 1 glass of wine with dinner and 1 shot of scotch before bed daily. Lives at home with wife. Retired professor; geology and civil engineering. Father: Pneumonia Mother: Stroke Adult sons: Alive and well. Grandparents: Unknown. Physical Exam: BP: 164/90 Pulse 102 RR 20 T 98.2 SpO2 91% Inspect skin: Numerous superficial, brown-pigmented, waxy skin lesions consistent with seborrheic keratosis; especially notable on anterior thorax. Inspect nails: Nails without ridging, pitting or peeling. exudate. Tongue normal color, symmetrical. No swelling or ulcerations. Gag reflex intact. Inspect neck: No visible scars, deformities or other lesions. Trachea is midline and freely mobile. No asymmetry or accessory respiratory muscle use with quiet breathing. Measure JVP (jugular venous pressure): Filling level of the jugular veins measured at 5-6 cm bilaterally. Positive hepatojugular reflux (HJR). Auscultate carotid arteries: No bruits Palpate all lymph nodes: No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary or inguinal chains. accessory muscles of respiration. Normal, symmetrical respiratory excursion No gynecomastia. Auscultate lungs: Fine crackles Palpate PMI: The PMI is palpated 2 cm lateral to midclavicular line within the 6th intercoastal space. Auscultate heart: Regular rate and rhythm. No gallops or murmurs. Visual inspection extremities: Swollen ankles bilaterally. No muscular wasting. Palpate extremities: 1-2+ bilateral pitting edema to upper shin. No calf tenderness. Auscultate abdominal/femoral arteries: No bruits Problem Statement: 74 y/o male with past medical history of HTN and CAD presents to the office today with complaints of progressive DOE and orthopnea over the last 2-3 months, associated with fatigue and lethargy. Patient reports having to use 3 pillows at night to help improve difficulty breathing. Patient states to have lower leg swelling, which is also worsening. Reports occasional episodes of palpitations. States to have a persistent dry cough, following a cold 3 weeks ago. Patient states over this time has noticed a 15 lb weight gain. Has recently discontinued use of all blood pressure medications 5-6 weeks ago. Denies any sweating, chest pain, wheezing, N/V, dizziness, or headaches. SOAP: Mr. Wilson's final diagnosis is new onset congestive heart failure. This is confirmed by several diagnostic findings including an elevated BNP of 630; which indicates moderate heart failure, abnormal EKG which demonstrates left ventricular hypertrophy with left atrial enlargement, c-xr with cardiomegaly, central pulmonary vascular engorgement, bilateral pleural effusions, R>L. The CMP reveals an elevated BUN, which can indicate an AKI. This reflects prerenal azotemia, which is due to reduced renal perfusion in the setting of heart failure. PE: Demonstrates an elevated BP, 164/90 with oxygen saturation of 91%. Patient is not in respiratory distress however is at risk for rapid deterioration. Patient with evidence of pitting edema to the lower extremities and fine crackles to bilateral lobes on auscultation. CBC is within normal limits eliminating infectious processes such as pneumonia. Acute coronary syndrome is also not supported due to the absence of chest pain and no evidence of MI on the 12-lead EKG. At this time patient should start immediate therapy. The patient should be restarted on an anti- hypertensive. In this setting, the primary options are ACE inhibitors or combo drug therapy such as sacubitril/valsartan. ACE inhibitors have been shown to decrease the morbidity and mortality associated with heart failure, and should be given to all patients with left ventricular dysfunction (National Institute for Health and Care Excellence, 2018). Additionally, the patient should also be started on a beta-blocker such as (prescription): Carvedilol: 3.125 mg orally (immediate-release) BID for 14 days (0 refills), 28 tablets. Beta-blockers have also been shown to decrease the morbidity and mortality associated with heart failure. Lastly, the patient should be started on an oral diuretic, which the primary option is furosemide to help with fluid overload. Important educational points for the patient are the importance of not discontinuing medications without consultation with the provider. The patient should also be advised to follow a low-sodium cardiac diet, which helps to reduce fluid retention. Daily weights are also important to help track the progress of diaresis and should be advised to record results daily. Mr. Wilson should also be advised to seek immediate medical attention if his shortness of breath worsens, develops chest pain, increased swelling or discomfort, and constant hacking cough. The patient should be reevaluated in 1 week to assess progress and determine the need for further treatment vs. possible referral to cardiology. Reference: National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. Sep 2018.