nrs 603 ihuman discussion, Assignments of Nursing

Download nrs 603 ihuman discussion and more Assignments Nursing in PDF only on Docsity! EHR & MANAGEMENT PLAN WK4 IHUMAN-SUSI GREEN-CC:DYSPNEA HISTORY Reason for encounter: Dyspnea HPI: S. G. is a 63-year-old female. CC is dyspnea that started today after she got off the plane. Pt reports she has to rest after walking 10-20 yards and has trouble walking up the stairs to the second floor in her son's house. Relieving factors include sitting down and rest. She reports problems with activities of daily living that she did not have before. General: Pt reports dyspnea that started today after flight from Florida to Chicago. She reports have to rest after walking 10-20 yards. Pt denies fever, chills, night sweats, weakness, cough, lower extremity edema, or chest pain. HEENT/Neck: Pt denies any history of headache, blurry vision or trouble swallowing. Cardiovascular: Pt denies any history of palpitations, chest pain, chest tightness, chest heaviness, heart attacks, murmurs, heart disease, heart failure, valve problems or leg, ankle or feet swelling. Pt reports having high blood pressure for years. Respiratory: Pt denies any history of asthma, cough, wheezing, DVT, blood clots in legs/lungs (PE), waking up at night or shortness of breath lying flat or at rest. Pt reports shortness of breath on exertion. sleeping with 1 pillow and is her normal. Gastrointestinal: Pt denies any history of nausea, vomiting, abdominal pain, changes in appetite, or weight gain. Genitourinary: Pt denies any history of trouble urinating. Musculoskeletal: Pt denies any history of arthritis, muscle pain, muscle cramping, problems with movement or involuntary strange dance like movements. Neurologic: Pt denies any history of weaknesses, syncope or feeling faint. Integumentary/Breast: Pt denies any history of any cancers. Psychiatric: Pt reports she has history of anxiety and depression. Endocrine: Pt denies any history of Diabetes, Hyperthyroidism, or Hypothyroidism. Hematologic/Lymphatic: Pt denies any history of bleeding. Allergic/Immunologic: Pt reports she has no allergies. Past Medical History: copd, anxiety, depression, high blood pressure. Hospitalization/Surgeries: Hospitalization: for delivery of children Surgeries: none Preventive Health: Denies having chicken pox, measles, mumps, rheumatic fever, strep throat as a child or TB. No recent dental procedures. Does not really exercise. Medications: Amlodipine 10 mg Daily Hydrochlorothiazide 25 mg Daily Tiotropium inhaler Daily Allergies: none Social History: Glass of wine 1-2x a week Quit smoking 26 years ago (19-36 y/o smoked) Salty foods: pizza just the past few days Family History: Father: died at 65, Parkinsons. Mother: died, massive stroke and had colorectal cancer. PHYSICAL EXAM General: S. G. is a 63-year-old female who is alert and oriented x 4, cooperative, of age stated, stressed and anxious. She is sitting upright in bed with marked increase in respiratory effort and catches breath mid-sentence. HHENT/Neck: HEENT/NECK-Head: Normocephalic atraumatic. Eyes: Ocular motor test normal. Fundoscopic exam shows red flex bilaterally and optic disks sharp. Nose: No polyps or discharge. No edema or tenderness over the frontal or maxillary sinuses on inspection. Mouth/pharynx: Oropharynx not injected, clear mucosa, tonsils without exudate. Tongue pink, symmetrical. No swelling or ulcerations Neck: Full range of motion. Thyroid moves with swallowing (normal exam). No JVD. Cardiovascular: Upon auscultation patient heart rhythm s4 and heart rate 92bpm on pulse assessment. Heart failure with preserved ejection fraction (HFpEF) is defined as a clinical diagnosis of HF with left ventricular ejection fraction (LVEF) ≥50% (Kittleson et al., 2023). The patients’ echo shows an EF of 55%. Another major diagnostic challenge with HFpEF is that there is no single test that definitively establishes the diagnosis, it is paramount to consider potential mimics, both noncardiac and cardiac, that may present with signs of congestion and/or symptoms of dyspnea, exercise intolerance, or congestion with preserved EF (Kittleson et al., 2023). Many individuals present first to their primary care clinicians with symptoms of dyspnea and exercise intolerance and/or signs of congestion and should be aware of HFpEF in the differential diagnosis of dyspnea, exercise intolerance, and edema; order relevant testing; be able to initiate GDMT; and recognize when a cardiology referral may be useful (Kittleson et al., 2023). The patient was referred to cardiologist for further management. The role of the cardiology specialist (cardiologist or cardiology advanced practice professional) is to exclude the presence of an alternative diagnosis to explain the individual’s presentation of dyspnea, edema, and preserved EF; optimize GDMT; encourage clinical trials; and identify indications for referral to an HF specialist (Kittleson et al., 2023). The patient was referred to cardiologist for further management. Management of HFpEF focuses on: 1) risk stratification and management of comorbidities, including hypertension, DM, obesity, AF, CAD, CKD, and obstructive sleep apnea; 2) nonpharmacological management, including the role of exercise and weight loss and the use of wireless, implantable pulmonary artery monitors; and 3) symptom management and disease- modifying therapy with loop diuretic agents, SGLT2is, mineralocorticoid antagonists (MRAs), angiotensin receptor–neprilysin inhibitors (ARNIs), and angiotensin receptor blockers (ARBs) (Kittleson et al., 2023). The patients Hydrochlorothiazide was increased to 25 mg twice daily. Enrollment in cardiac rehabilitation programs or structured exercise therapy could improve the quality of life and functional capacity of individuals with HFpEF, especially those with prior hospitalization (Kittleson et al., 2023). The patient was referred to cardiac rehabilitation. Referral I would transfer this patient by ambulance to the closest hospital for admission for oxygen management. I would refer her to cardiology and cardiac rehabilitation after discharge. Follow-up Patient is to be continued care in the hospital at this time. She will follow up after discharge home for a transition of care visit in the office. Follow-up in office within 3-5 days from being discharged for symptom management, review of medication, and home oxygen evaluation. If you are not able to make your appointment schedule a telehealth visit in 3-5 days. If you develop chest pain, increasing shortness of breath, uncontrollable fever, or the feeling of fainting go to the nearest emergency room or call 911. References Epocrates. (2024, May 27). https://www.epocrates.com/online/drugs/222/hydrochlorothiazide Kittleson, M. M., Panjrath, G. S., Amancherla, K., Davis, L. L., Dixon, D. L., Januzzie, J. L., & Yancy, C. W. (2023). 2023 ACC expert consensus decision pathway on management of heart failure with preserved ejection fraction. Journal of the American College of Cardiology 81 (18), 1835-1878. https://doi.org/10.1016/j.jacc.2023.03.393