case studyOrder DescriptionHERE IS THE CASE STUDY:Week 1: Cardiovascular Clinical CasePatient Setting:52 year old Irish American Male that was hospitalized 2 weeks ago for a stent placement. Presenting to your clinic today for follow up as he has not felt well. He sates he has been lightheaded and felt palpitations of his heart. He has also had shortness of breath the last 2 days.HPIWalks 2 miles daily and rides an exercise bicycle 3 times a week; has previously felt the palpitations associated with exercise that usually went away with rest; 2 days ago while washing dishes he began to feel shortness of breath and felt that his heart was “racing”; He hoped the palpitations would go away but they have continued and that is why he is here today.PMHHistory of hypertension for 10 years, hyperlipidemia for 5 year, status post stent placement 2 weeks ago, and rheumatic heart disease (mitral valve) as a child. He reports adhering to a low cholesterol low fat diet for the last 2 years.Past Surgical HistoryStent placement 2 weeks ago.Family/Social HistoryFamily: NoncontributarySocial: Smoked 15 pack/year X 20 years. Quit 5 years ago.Medication HistoryLisinopril 20 mg PO QDFurosemide 20 mg PO QDGemfibrozil 600 mg PO BIDAllergiesNKDAROSOtherwise negative.Physical examBP 160/90 (clinic visit 2 months ago 155/85) HR 146, RR 22, T 98.6 F, Wt 254, Ht 5’ 7”Gen: Well developed male in moderate distress. HEENT: PERRLA, (-) JVDm mild AV nicking. Cardio: Rate irregularly irregular, no murmurs or gallops. Chest: Clear to auscultation. Abd: soft, non-tender, active bowel sounds. GU: Deferred. Rectal: Normal. EXT: No edema, normal pulses throughout. NEURO: A&O X3.Laboratory and Diagnostic TestingNa – 136K – 4.5Cl – 97BUN – 20Cr – 1.2Total Chol – 240Trig – 180INR – 1.1Chest Xray – ClearECG – Atrial Fibrillation, no P waves, variable R-R interval normal QRSHERE BELOW IS THE TEMPLATE TO FOLLOW IN COMPLETING THE ASSIGNMENT. THE MAIN FOCUS IS THE CARE PLAN WITH PRIORITY DIAGNOSIS FROM THE CASE STUDY.**Please delete this statement and anything in italics prior to submission to shorten the length of your paper.Patient Initials ______Subjective Data: (Information the patient tells you regarding themselves: Biased Information):Chief Compliant: (In patient’s exact words)History of Present Illness: (Analysis of current problems in chronologic order using symptom analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated symptoms and treatments tried]).PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history, obstetric and history sexual history).Significant Family History: (Includes family members and specific inheritable diseases).Social History: (Includes home living situation, marital history, cultural background, health habits, lifestyle/recreation, religious practices, educational background, occupational history, financial security and family history of violence).Review of Symptoms: (Review each body system – This section you should place POSITIVE for… information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes: ; ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:; Neurological:; Endocrine:; Hematologic:; Psychologic: .Objective Data:Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .Physical Assessment Findings: (Includes full head to toe review)HEENT:Lymph Nodes:Carotids:Lungs:Heart:Abdomen:Genital/Pelvic:Rectum:Extremities/Pulses:Neurologic:Laboratory and Diagnostic Test Results: (Include result and interpretation.)Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of priority.)Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided).
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