Mr. Sullivan, a 79 y/o current 1
Mr. Sullivan, a 79 y/o current 1 pk/day smoker for over 50 yrs, carries the diagnoses of Hypertension (HTN), Hyperlipidemia (HLD) & a relative new diagnosis of Coronary Artery Disease (CAD), s/p ST Elevation Myocardial Infarction (STEMI). Two weeks ago he had the STEMI & underwent Percutaneous Coronary Angioplasty (PTCA) with stent placement to the Left Anterior Descending (LAD) Coronary Artery. He presents to the Health Clinic today for a routine follow-up following his MI. He tells the Health Care Provider that he is short of breath (SOB) lately & has been sleeping in the recliner for the past week as he would wake up with air hunger when sleeping in bed. He tells you that he now gets SOB walking up the driveway after retrieving his newspaper in the morning. He also tells you that his socks are quite tight around his ankles & his shoes seem too small. He has no medication or food allergies. Home medications include: EC ASA 81 mg daily, clopidogrel 75 mg daily, metoprolol tartrate 50 mg q 12 hr, lisinopril 5 mg daily, atorvastatin 40 mg hs, and NTG SL prn chest pain. Vital Signs: BP 156/88, HR 110, RR 26, POX 90% RA, Temp 97.8. Weight 86 kg today; on hospital discharge weight documented at 81 kg. Physical Assessment: Neuro A & O x3; Neck +JVD to the ear lobe; Lungs crackles throughout; Heart Sounds regular, tachycardic, S3, S1,S2, no murmurs appreciated; Abd soft, nontender, non-distended, bowel sounds +; Extremities PP+, 3+ pitting pedal edema. Response to the Questions: He has now developed Heart Failure (HF). This is a new diagnosis, beyond those in his history. Explain the pathophysiology r/t to this top priority diagnosis of HF. Why did he develop HF? What Client History & Assessment Data help support the priority diagnoses of HF? Do the clients’ new & old medical diagnoses link together? If so how?
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