Chief Informant: Patient (Akana, Keola) Chief Complaint: “Heart…
Question Answered step-by-step Chief Informant: Patient (Akana, Keola) Chief Complaint: “Heart… Chief Informant: Patient (Akana, Keola)Chief Complaint: “Heart failure complications” H O S P I T A LHistory of Current Problem: Patient reports a history of shortness of breath with exercise for the past several months. One week ago he experienced worsening shortness of breath including mild dyspnea at rest. Primary provider added digoxin to medication regimen 3 days ago. Patient reported continued worsening dyspnea and provider ordered direct admission for medication adjustment, monitoring, and cardiac rehabilitation.Allergies: NonePrevious Illnesses: No significant historyInjuries or Trauma: No significant historySurgical History: NoneDietary History: Cooks for self and wife. Prefers traditional Hawaiian foodsSocial History: Second marriage. Lives with wife. Has 3 adult children.Current Medications: Furosemide 40 mg by mouth daily, digoxin 0.25 mg by mouth daily, atenolol 50 mg by mouth daily, potassium chloride 10 mEq by mouth daily.Review of SystemsIntegument: No reported concerns.HEENT: Mild headache this morning which the patient attributes to the transfer vehicle ride. No history of headaches. No recent changes in vision or hearing.Cardiovascular: No history of hypertension. Denies chest pain. Swelling in ankles and feet.Respiratory: No recent respiratory infections. Complains of recent increased difficulty breathing even at rest.Gastrointestinal: Denies issues. Bowel movements regular.Genitourinary: Denies frequency, urgency, or recent changes in urination. Musculoskeletal: Denies pain in joints or back. Reports weakness related to shortness of breath.Neurologic: Denies movement and sensation issues. Denies problems with cognition or memory.Endocrine: No reported concerns.1) MAke SBAR Laboratory ResultsBasic Metabolic PanelBlood Urea Nitrogen40 mg/dLChloride103 mEq/LCarbon Dioxide30 mEq/LCreatinine2.3 mg/dLGlucose149 mg/dLPotassium5.8 mEq/LSodium134 mEq/LCalcium8.8 mg/dLDigoxin LevelDigoxin level2.3 ng/mL Health Science Science Nursing Share QuestionEmailCopy link Comments (0)
