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In: Nursing

DDA Cardiac Module CC: Shortness of breath, cough and fatigue HPI: Mrs. Short is a 74...

DDA Cardiac Module

CC: Shortness of breath, cough and fatigue

HPI: Mrs. Short is a 74 year old Caucasian female with h/o of HTN and RA. She is very active at the senior center with group activities and exercise class. She presents today because she feels “her energy is drained” and she cannot get over a cough. She has been seen in the clinic 3 times over the past year for the cough. She was treated each time with antibiotics but has not gotten much better.

ROS: denies fever or night sweats, +fatigue, appetite ok, denies HA or vertigo, denies syncope or presyncope, +SOB on exertion, denies orthopnea, +palpitations, denies chest pain, denies any GI/GU complaints, +edema, +joint pain in hands that is chronic due to RA

PMH: HTN, RA – last visit with rheumatologist was “years ago” because she did not want to take DMARDs, GERD, osteopenia, menopause

Diagnostic testing: EKG 2015 that showed LVH with normal rhythm, ECHO 2012 with normal LV function, DEXA 2010 TScore -1.9

Labs: she had “complete workup” for PE 2 years ago but doesn't know the results

SH: married for 45 years with 4 adult children who live in area, never smoked, +ETOH 2-3 glass of wine daily, no illicit drug use, works part time in real estate. Fully independent in all ADLs, IADLs.

FH: Father side of family with T2DM and HTN.

Meds: metoprolol XL 50mg qd, ASA 1mg qd, Calcium 1000mg daily, Pepcid 20mg qd, Tylenol as needed for pain

Allergies: NKDA

Physical Exam:

VS: BP 142/90, P90, R18, SPO2 98% on RA, height 60in, weight 150lbs, BMI 29.3 (up 7lbs in 6 mos)

General: slightly obese female in NAD, appears well groomed and well nourished.

HEENT: normocephalic, PERRL, teeth in good repair, buccal mucosa moist

Neck: No JVD, No bruits, No thyromegaly

CV: S1S2, RRR, II/VI SEM, +S3

Lungs: CTA A/P, no wheezing

Ext: 1+ BLE edema, pedal pulses 2+ bil, no calf tenderness,

Abd: soft, nontender, BS+, no heptamegaly or splenomegaly

Skin: no lesions or rashes

Neuro: nonfocal, CN 2-12 grossly intact

MS: small joint deformities and synovitis present in bil hands. Slight tenderness in joints of fingers, strength 5/5 in bil hands, ROM slightly limited in fingers.

What are her medical diagnoses?

What are her differential diagnoses, with rule outs?

What diagnostics are needed?

What prescriptions does she need?

What education does she need?

Solutions

Expert Solution

Medical diagnosis
plapitaiton, cough, fatigue, shortness of breath, edema, joint pain in hands
diffetial diagnosis:
hypertension, rheumatoid arthritis
Diagnostic test:
Xray chest, to look for heart enlargement, lung function test to measure lung capacity, chest CT scan, and chest MRI to see the heart size, ESR, CRP to see the inflammation.
Prescription:
Patient need diuretics to reduce the fluid buildup
oxygen therapy to reduce the shortness of breath and improve o2 level in blood.
vasodilators to improve blood flow
Digoxin to strengthen the heart
Bronchodilator to improve airflow and dilate the pulmonary blood vessels
Education:
-advice the patient to follow a healthy diet, low fat and low carbohydrate diet with limited water and salt
-advice the patient to take adequate rest
-can do only moderate exercise
-advise the patient to avoid prolong standards and lifting.
- advise the patient to maintain healthy  weight.



Nightingale answered 1 year ago
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