EXAMPLE #5: Patient with History of Congestive Heart Failure |
Subjective:Patient G.P. is a 64 y/o male who presented to the ED with complaints of S.O.B. when resting and swelling of both feet and legs. He arrived at the ED by private vehicle accompanied by his spouse. Pt reports swelling in feet and legs began about “five or six days ago” and that S.O.B. “never goes away.” Pt has a history of CHF and is admittedly non-compliant with medication regimen. He has a prescription for Lasix 40 mg. qd but states, “It’s been a while since I took it” and indicates the constant need to use the restroom makes him not want to take his medication. Pt. also has an order for 02 per NC @ 2L continuous but also reports smoking at least ½ PPD of cigarettes. His wife reports the swelling in his legs has gotten progressively worse in the last several weeks, and his cough is also worse. Pt. reports his cough is productive with thick, yellow sputum. Denies pain, fever, aches, vomiting, or diarrhea. No other complaints voiced. Past medical hx: CHF, HTN, Atrial Fib; no surgeries; last hospitalization 11 months ago for exacerbation of CHF at which time pt left the hospital AMA. Current medications: Lasix 40 mg qd (not taking), Lopressor 25 mg BID, Losartan 50 mg qd. Smokes ½ to 1 PPD cigarettes x 25 yrs. Denies the use of alcohol or illegal drugs. Family medical hx: Paternal HTN, MI, and CVA, Father died from complications of MI; Mother: Breast CA, DM, HTN. Objective:Pt. is an A&O male who appears mildly agitated; skin is pale and clammy. Vital Signs: B/P 160/94, P 82, R 24, T 98.3, Sp02 92%. Weight today is 249 lbs. Pt reports he weighed at home two days ago and weighed 243 lbs. Bowel sounds active x4, abdomen nontender. Bilateral lung bases positive for crackles; no retraction, symmetrical rise and fall of the chest. Pulses present X 2 upper & lower extremities. 3+ pitting edema in bilateral lower extremities. 12-Lead EKG shows Atrial Fibrillation, CXR shows cardiomegaly but no acute cardiopulmonary abnormality; CBC and CMP today WNL. Assessment:Based on orthopnea, S.O.B. with minimal exertion, BLE edema, weakness, and fatigue, pt. is likely experiencing an acute exacerbation of CHF. S.O.B. and hx of smoking could be indicative of COPD. However, BLE edema suggests the more appropriate diagnosis is CHF. Plan:Pt. admitted to telemetry for O2 support, evaluate for diuresis r/t fluid overload, and cardiac workup. Echocardiogram and stress test ordered for tomorrow a.m. Continue home meds except for Lasix po. Start Lasix 40 mg IV twice daily; Monitor I & O; Educated patient on importance of medication compliance and the risk to cardiovascular and pulmonary health from smoking. Pt agrees to try nicotine patch to “see if it works.” |