Cardiovascular Clinical Case
Patient Initials
An Irish American male patient aged 52 years.
Chief Complaint
Lightheadedness, palpitations of the heart, and shortness of breath for two days.
History of Presenting Illness
The patient presented to the hospital two weeks after hospitalization for a stent placement complaining of light-headedness, palpitations, and shortness of breath. The shortness of breath started when he was washing dishes two days ago accompanied by palpitations that he hoped would stop but persisted forcing him to seek medical attention. The palpitations were previously associated with exercise as an aggravating factor. The patient reports that resting relieved palpitations that ensued every time he engaged in exercise such as walking and riding. For the last two days, the palpitations have not been time specific as they started while he was washing his dishes and has not stopped.
Past Medical and Surgical History
The patient has a history rheumatic heart disease affecting the mitral valve that was diagnosed when he was a child, he has been hypertensive for a period of 10 years, he has a five-year history of hyperlipidemia, and surgical procedure involving stent placement that was done two weeks ago. He reports adhering to a low cholesterol diet for the last two years, an intervention for controlling hypertension. The patient has no any known drug allergies and food allergies, and he has no psychiatric disorders whatsoever. He has been on Lisinopril 20mg PO QID and Furosemide 20mg PO QID for the management of hypertension and Gemfibrozil 600mg PO BID for hyperlipidaemia.
Family and Social History
The history of the patient’s family is not significant in relation to the condition of the patient thus non-contributory. However, the patient has a long history of smoking, a habit the he quit last five years ago. He used to smoke 15 packs of cigarette every year for a period of 20 years until five years ago.
Review of Systems
All systems were reviewed are negative.
Objective Data
The patient’s Blood Pressure is 160/90 as compared to 155/85 that was recorded 2 months ago during a clinic visit. The Heart Rate is 146 beats per minute, Respiratory Rate 22 breaths per minute, the Temperature is 98.6 F, weight 254lb, and the Height is 5’7”.
General Examination
The patient is middle-aged, male, well-nourished, and in moderate distress. HEENT and PERRLA examination is negative with no significant abnormalities discerned. An examination on Axillary, the sub-mental, sub-mandibular, posterior and anterior auricular, occipital and inguinal lymph nodes was negative with no significant nodes observed. On examination of the neck, there is mild Jugular Venous Distension (JVD) with AV nicking. Cardiovascular assessment, the pulse rate is irregularly regular, no murmurs or gallops were picked. On examination, the chest is clear for auscultation, the abdomen is soft, non-tender with active bowel sounds. The genitourinary system is deferred and the rectum being normal. There is no edema, on examination of extremities with the neurologic exam being A&O X3.
The Laboratory and Diagnostic Tests
Laboratory tests revealed the following; a normal QRS wave, Variable R-R interval, absent P waves, ECG showed Atrial fibrillation, Chest X-ray was clear, Triglycerides – 180, INR – 1.1, Total Cholesterol – 240, BUN – 20, Cr – 1.2, Na – 136, K – 4.5, and Cl – 97.
Assessment
D50-D89: Risk for heart failure related to high blood pressure (BP 160/90) and narrowing of the coronary artery through deposition of cholesterol and the stent (Manchikanti et al., 2013).
I00-I99: Respiratory distress seen as shortness of breath related to inadequate pumping of blood by the heart (Manchikanti et al., 2013).
I00-I99: Dizziness (light-headedness) related to extremely high blood pressure (160/90), tachycardia (146 beats per minute) and narrowing of blood vessels that supply the brain because of hyperlipidemia (Weber et al., 2015, Piepoli et al., 2016).
Plan of Care
Encourage the patient to adhere to anti-hypertensive medication that he has been taking in order to prevent exponential increase in the blood pressure. Additionally, monitor vital signs especially the blood pressure and control it according to the medical intervention in place (Weber et al., 2015, Piepoli et al., 2016). Encourage rest in order to reduce oxygen requirement by the heart, which is predisposition to palpitations. Lastly, encourage the patient to control his dietary and system cholesterol through diet monitoring and prescribed drugs (Gemfibrozil) to reduce the narrowing of coronary arteries and deposition on the stent inserted in his blood vessel (Tan, Wu, & Yevzlin, 2015, Piepoli et al., 2016). As for the respiratory distress, encourage rest and monitoring of cardiac activity in order to enhance pumping of blood (Tan et al., 2015). Further, control the high blood pressure and increased heart rate through prescribed medication. Lastly, encourage slow and deep breathing, as the patient’s RR is relatively high.
The nursing intervention for dizziness would be to control the high blood pressure through adhering to medication, intervene and reduce the heart rate to below 100 by drugs such as Metoprolol, which as a beta-blocker calcium channel blockers such as Verapamil as per medical prescription (Tan et al., 2015). Further, adhering to lipid lowering medication, Resting and encouragement of relaxation techniques will go along way in helping relieve dizziness (Weber et al., 2015).
References
Manchikanti, L., Falco, F. J., & Hirsch, J. A. (2013). Ready or not! Here comes ICD-10. Journal of Neurointerventional Surgery, 5(1), 86-91. doi: 10.1136/neurintsurg-2011-010155.
Piepoli, M. F., Hoes, A. W., Agewall, S., Albus, C., Brotons, C., Catapano, A. L., … Graham, I. (2016). 2016 European Guidelines on cardiovascular disease prevention in clinical practice The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). European Journal of Preventive Cardiology, 7(29), pp.2315-2381. doi: 10.1093/eurheartj/ehw106..
Tan, C. S., Wu, S., & Yevzlin, A. S. (2015). Endovascular Stent Placement. In Dialysis Access Management (pp. 159-167). Springer International Publishing.
Weber, M. A., Schiffrin, E. L., White, W. B., Mann, S., Lindholm, L. H., Kenerson, J. G., … Cohen, D. L. (2014). Clinical practice guidelines for the management of hypertension in the community. The journal of clinical hypertension, 16(1), 14-26. doi:10.1111/jch.12237
