NR 601 Week 2 SOAP -Acute Diastolic HF

NR 601 Week 2 SOAP -Acute Diastolic HF

NR 601 Week 2 SOAP -Acute Diastolic HF

B.J., 70 YOF, Black

Subjective

CC: Shortness of breath; medication refill (anti-hypertensive)

O: Legs and ankles swollen since last week

L: Legs and ankles

D: unknown

C:  Increased SOB with activity and when laying down at night

A: Worse when playing with grandchildren and sleeping

R: Sitting down to rest, sleeping upright with 3 pillows

T:  unknown

PMH:

Hx of HTN, and MI in 2010

Unknown childhood illnesses

Surgery: 2010- Left Anterior Descending (LAD) cardiac stent placement

Immunizations and Screenings:

Receives annual flu shot (last year)

Not up to date: Pneumovax, Td, herpes zoster

Last Colorectal Screening 11 yr ago

Last Mammogram 5 yr ago

Never had DEXA/Bone Density Test

Last dilated eye exam 4 yr ago

Last labs: Hgb 12.2, Hct 37%,  K+ 4.2, Na+140 Cholesterol 186, Triglycerides 188, HDL 37, LDL 190, TSH 3.7

 

Allergies: Amoxicillin

Current medications:

Coreg 6.25 mg PO BID

Colace 100 mg PO BID

K-dur 20 mEq PO QD

Furosemide 40 mg PO QD

Has not taken any prescription medicine in approximately 6 months.

NR 601 Week 2 SOAP -Acute Diastolic HF

Social History

She graduated from high school, and thought about college, but got married right away and then had kids a short time later. Her son lives in another state. Former smoker that stopped 20 years ago.  Drinks one 4-oz glass of red wine daily.

Family History

Mom- deceased of natural causes

Dad- deceased from MI

Brother – deceased of MI at age 52.

Other:

ROS

Constitutional: Have you had any weight gain or weight loss in the last month? Do you feel weak? Fatigued? Excessive sweating? Difficulty falling asleep or staying asleep?

HEENT: Do you have any headaches? Eye drainage? Blurred vision? Nasal discharge? Sinus pressure? Changes in hearing? Throat pain? Swelling?

Cardiac: (+) edema to ankles and feet bilaterally; Do you have any chest pain, palpitations, dizziness?

Respiratory: (+) SOB, (+) orthopnea (better with 3 pillows); Are you wheezing? Do you have a cough? How many blocks can you walk without becoming short of breath?  How many blocks could you walk 6 months ago? Is the shortness of breath constant? Does it occur suddenly?

GI: Do you have any nausea or vomiting, heartburn or indigestion?

GU: Do you have any problems with urination?

Lymphatics: Do you have any enlarged lymph nodes

Extremities:   (+) edema bilateral ankles and feet

 

Assessment

Vital Signs

Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8   BP 150/86 T 98.0 po P 100 R 22, non-labored

HEENT: normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower dentures in place a fitting well. No tinnitus

NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. Thyroid non-palpable

LUNGS: inspiratory crackles

HEART: Normal S1 with S2 split during expiration. An S4 is noted at the apex; systolic murmur noted at the right upper sternal border without radiation to the carotids.

ABDOMEN: Normal contour; active bowel sounds all four quadrants; no palpable masses.

PV: Pulses are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally

GENITOURINARY: no CVA tenderness; not examined

MUSCULOSKELETAL: Heberden’s nodes at the DIP joints of all fingers and crepitus of the bilateral knees on flexion and extension with tenderness to palpation medially at both knees. Kyphosis and gait slow, but steady.

PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22.

SKIN: Sparse hair noted on lower legs and feet bilaterally with dry skin on her ankles and feet.

NR 601 Week 2 SOAP -Acute Diastolic HF

Primary Diagnosis

1. Acute Diastolic (Congestive) heart failure (I50.31) – …

Secondary Diagnoses:

1. Hypertension (R03.0) – …
2. …
3. …
4. …

Differential Diagnosis

1. Nonrheumatic mitral (valve) insufficiency (I34.0) – The mitral valve is located between the left atrium and left ventricle. Any type of mitral valve insufficiency can result in backflow of blood into the left atrium.  If left untreated, patients are at risk for developing ventricular arrhythmias that could be life threatening (Khan et al, 2015).  Symptoms include orthopnea, shortness of breath on exertion, fatigue, and possible refractory congestive failure (Gorroll & Mulley, 2014).  There is no evidence that this patient has had an echocardiogram and therefore we can not rule out mitral valve insufficiency.

Plan of Care

Diagnostics:

• Blood work: …
• …

Medications:

New-

Losartan .  This medication is an ARB which works by decreasing the heart’s workload.  This, in conjunction with a beta blocker and diuretic is the recommended treatment for heart failure (NIH, 2016).

Losartan 50 mg tablet

1 tablet daily

Dispense 30, refill: 2

Atorvastatin.  This medication is considered a high-intensity statin which is what is recommended for this patient based on her LDL’s (AAFP, 2014).  Atorvastatin 40mg to 80 mg is recommended to treat hyperlipidemia.  I would start this patient on 40 mg then check her lipid panel in 12 weeks to adjust dosage.

Atorvastatin 40 mg tablet

Take 1 tablet daily

Dispense 30, Refill: 2

Zoloft .  This medication is an SSRI, which helps the brain hold on to the serotonin longer (NIH, 2016).

Zoloft 25 mg

1 tablet daily

Dispense 30, refill: 2

 

NR 601 Week 2 SOAP -Acute Diastolic HF

Continued-

Coreg 6.25 mg PO BID. This medication is a beta blocker which is recommended for heart failure patients.

K-dur 20 mEq PO QD

Furosemide 40 mg PO QD.  This is a diuretic suggested for heart failure patients, especially during an exacerbation.

STOP TAKING:

Colace 100 mg BID.   I am not sure why this patient is taking this medication, but it should not be used long term.  Patient should try increasing fiber in her diet and making other lifestyle changes.

Patient Education:

Heart Failure –

• Take medications as directed.
• It is important to stay active and slowly increase distance walked (US National Library of Medicine, 2017).
• Eat 5-6 smaller meals every day and try to avoid increased fluid intake. Reduce sodium intake as well. Avoid canned vegetables and frozen dinners.  Follow a low sodium, low cholesterol diet with a 2 gram sodium intake.
• Call your provider if you have a weight gain of 2 pounds in one day.
• Take Lasix in the morning because the medication will cause excessive urination. This will prevent you from waking up in the middle of the night  (US National Library of Medicine, 2017).
• Call provider immediately if you have a notice yourself increasing the workload of your breathing or feel the need to lean forward when taking a breath (US National Library of Medicine, 2017).
• Call 9-1-1 if you are experiencing chest pain or extreme shortness of breath (US National Library of Medicine, 2017).

Hypertension –

• Continue taking medications as directed.
• Try to keep a journal of blood pressures in the morning. Use a portable wrist BP machine.
• Avoid foods high in sodium or cholesterol (Gauer, 2017).

Overweight –

• Begin an exercise regimen once you feel you are able to increase your activity level walking 30 minutes three times per week.
• maintain a healthy diet.  Apps like myfitnesspal can help you keep on track.

Osteoarthritis –

• Once swelling is reduced, begin exercise regimen with non-weightbearing exercises. Swimming is a great example on a non-weightbearing exercise.

Depression –

• Begin by breaking medication in half the first four days to prevent side-effects (Frank, 2014).
• Call 9-1-1 immediately with any thoughts of hurting yourself or suicide.

Medications –

• Furosemide can cause hypotension, dizziness, and lightheadedness. Be sure to take medication in the morning (Gorroll and Mulley, 2014).
• Losartan should be taken at the same time every day.
• Coreg may cause you to experience bradycardia, symptoms of low blood sugar, hypotension, or heart block. Please tell your provider immediately if you develop any of these symptoms (Epocrates, 2016).
• Do not stop taking any medications without speaking with your provider. This can result in rebound hypertension and worsening heart failure.

Referrals/Consults: Patient should follow up with cardiologist within one week (Gorroll & Mulley, 2014).

Follow-up: Patient should return to office in 2 weeks to evaluate if medication regimen is working.

NR 601 Week 2 SOAP -Acute Diastolic HF

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References

AAFP. (2014). Treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. Retrieved from http://www.aafp.org/patient-care/clinical-recommendations/all/cholesterol.html

Brauer, S. (2012). Osteoarthritis. Journal of Physiology, 58(2); 133.

Centers for Disease Control and Prevention. (2017). Defining adult overweight and obesity. Retrieved from https://www.cdc.gov/obesity/adult/defining.html (Links to an external site.)Links to an external site.

Elsawy, B., & Higgins, K.E. (2011). The geriatric assessment. American Family Physician, 83(1): 48-56.

Epocrates. (2016). Coreg. Retrieved from https://online.epocrates.com/u/101535/Coreg/Adult+Dosing

Gauer, R. (2017). Severe Asymptomatic Hypertension: Evaluation and Treatment. American Family Physician, 95(8), 492-500.

Goroll, A. H., & Mulley, A. G. (2014). Primary care medicine: Office evaluation and management of the adult patient (7th ed.). China: Wolters Kluwer.

Green, P., & Maurer, M. S. (2013). Geriatric Assessment of Older Adults with Heart Failure: An Essential Tool in Planning of Care. The American Journal of Medicine, 126(2), 93–94. http://doi.org/10.1016/j.amjmed.2012.11.007

Khan, M. A., Imran Majeed, S. M., & Sarwar, M. (2015). Association of ventricular late potentials with mitral regurgitation in patients with mitral valve prolapse. Pakistan Armed Forces Medical Journal, 65(1), 125-129.

Lambert, M. (2014). ACC/AHA release updated guideline on the treatment of blood cholesterol to reduce ASCVD risk. American Family Physician; 90(4): 260-265.

Lowe, R. N., Marrs, J. C., & Saseen, J. J. (2013). Patterns of serum laboratory monitoring for safety and efficacy in patients on chronic statin therapy. Therapeutic Advances in Drug Safety, 4(1), 9–17. http://doi.org/10.1177/2042098612474293

Marwick, T.H. (2015). The role of echocardiography in heart failure. The Journal of Nuclear Medicine, 56(4): 431s-438s. http://jnm.snmjournals.org/content/56/Supplement_4/31S.full

National Heart, Lung, and Blood Institute. (2016). How is heart failure treated?. Retrieved from https://www.nhlbi.nih.gov/health/health-topics/topics/hf/treatment

US National Library of Medicine, (2016). Bone mineral density test. Retrieved from https://medlineplus.gov/ency/article/007197.htm

US National Library of Medicine, (2016). Heart failure. Retrieved from https://medlineplus.gov/heartfailure.html