Mr. Abrenica, Case Study Example

Chief Complaints

• Patient feeling easy fatigability
• Patient feeling Dizziness
• Not feeling Right

History of Presenting Illness

Patient was well until three weeks ago when he started feeling that everything was not going on well in his body. He had been feeling dizziness for some time which was approximately three weeks. In addition, when he climbs on a mountain or does work which is hard, he would become easily tired. This has been there for the last twenty seven days. These are the things which were making the patient feel that something is not right. Before the illness, he was not suffering from any other condition. He was seen on a clinic for emergence and given Vasotec, five mgs per day and also some antacids. He has no history of eye problems although he uses glasses. In the last three years, he has had an increase of his weight which is about sixty pounds. This may be due to the diet he has been having in the last three years. He takes a diet rich in carbohydrates and salt and fats. He does not take a lot of fruits and vegetables. In one night, he sleeps for about seven hours.

He has a history of polyuria since he must get up at night to go to the washrooms. Since he sleeps for about seven hours, when he is sleeping he must wake up at least once in the night. In the normal person, sleeping for seven hours should not necessitate the person to wake up and go to the washrooms. He always snores at night indicating that at times he has respiratory distress. There is compromise in the sexual function partly because of easy fatigability and also because he is unable to maintain an erection. This means the blood supply of the penis has been compromised. He does not do a lot of exercise and works in office with very little manual work. Therefore he does not do exercise.

There is a history of high blood pressure in the family with his mother who died at the age of seventy eight. She died of complications of hypertension called stroke. The brother of his dad also died of heart attack which also may be associated with hypertension. He has no history of chest pain or paroxysmal nocturnal dyspnea. He has no history of palpitations or awareness of heartbeat. He says that there is no change in the rate or force of beating of the heart. The patient has not had difficulty in breathing. There is no history of problems in passing urine and no history of patient having pain in the abdomen.

Family Social History

Mr. Abrenica is married to a wife who is about thirty two years of age. He has four children. Among the relatives, there is history of chronic illnesses like hypertension. For example, his uncle, who is brother of his dad, died of heart attack which is closely associated with hypertension as a complication. His mother died at the age of seventy eight years due to a complication of hypertension called stroke.

History of Allergy and Medications

Since three weeks ago, he has been taking Vasotec 5mg two times a day. He also takes anti-acids almost on a weekly basis. He has no know drug allergy. In addition, he does not have any food allergy. The patient is not on any chronic medications either for diabetes, tuberculosis of other chronic illnesses. The patient does not smoke tobacco or any other drugs from the streets. He takes alcohol, one glass of wine per day.

Occupational History

He is a specialist in Information technology. He does not do any manual work. He feels difficulty in running his business.

Review of Other Systems

Cardiovascular: No history of headaches, no history of convulsions, no history of confusion. The patient has never lost his consciousness in the past and has never experienced episodes of memory lapse.

Genital-Urinary System: The patient has a history of increased rate of passing urine. He has no history of pain in the region of the flanks. No history of passing blood in the urine.

Respiratory System: No history of cough, no history of difficult in breathing. Patient did not have a history of chest pain.

Physical Examination:

General Examination

Mr. Abrenica is in fair general condition not in obvious pain and not in obvious respiratory distress. He is about six feet tall and his weight is about two hundred and seventy five pounds. He has no pallor, no cyanosis, and no lymphadenopathy. The patient has no oral thrush and no finger clumping.

Vitals

• Respiratory Rate: eighteen breaths per minute.
• Pulse rate: eighty six Beats per minute.
• Blood Pressure: 150/90 milliliters of mercury.
• Temperature: 98

Central Nervous System and Musculoskeletal system

Patient is oriented in time position and place. His memory is intact and his speech is okay. His neck is not stiff and no kerning’s sign in the patient. In the examination of the cranial nerves, only the eyes have a pale ring color. The eyes have small nodules which have a waxy appearance. His nails are thickened and the area around the ankle joint is swollen On the calves, the skin seems to have a deep red coloration.

Cardiovascular Examination

Pulse rate is eighty six beats per minute. It is regular in the rhythm and of normal volume. The pulses of all the arteries are the same and there is no pulse delay. There are no bruits in the pulses. The pericardium is normative; there is no raised jugular venous pressure. The auscultation of the heart reveals S1, S2 and S4. This heart sounds are specifically audible at the level of fifth intercostals space mid-clavicular line on the left representing the apex of the heart.

Investigations

Electrocardiogram: Shows signs of left ventricular hypertrophy.

Diagnosis

Congestive heart failure: left ventricular failure with hypertrophy secondary to hypertension.

Plan

• Admit the patient for close monitoring
• Control the hypertension
• Administer diuretics to the patient
• Do an echocardiogram
• Perform a urinalysis
• monitor the vitals four hourly
• urinalysis
• Kidney function tests which include the electrolytes, urea and creatinine

Implementation

The patient should be taken to the cardiac ward. There, the nurse assigned the patient should monitor the patient, recording the vitals on a four hourly basis (Mary, 2009). Diuretics should be administered to reduce the blood pressure (White & John, 2010). In addition, the patient should be observed for the urine output. The echocardiogram will help in the further confirmation of the left ventricular hypertrophy. Kidney function tests will check for evidence of effect of increased blood pressure on the kidneys.

Evaluation

The evaluation of the patient will be achieved by checking if there is an increased blood pressure in the patient (John, 2008). In addition, it will help to establish if the treatment is effective to reduce the blood pressure. Therefore, the blood pressure should be checked frequently. The urine output should also be recorded. Auscultation of the heart will provide some clue on if there is a still problem with the heart. An electrocardiogram should be performed again to check if the patient is recovering (Nancy & Charles, 2006).

Soap Note

A fifty eight year old Abrenica who is married with four children presented with a history of not feeling well for about three weeks, has had his blood pressure being 170/118 milliliters of mercury. He has been taking Vasotec 5mg BD and some antacids once weekly. He has also noticed inability to erect and easy fatigability for about three weeks from now. He has no history of smoking, no history of taking street drugs. On examination, the pulse rate is normal, the pericardium is normal but on auscultation, there is an S1, S2 and S4 on the level of fifth intercostals space left mid-clavicular line. An Echo done on him showed left ventricular hypertrophy.

References

John, F. (2008). Care of Cardiac patients. Annual Journal of practice of nursing, 6 (12), 45-67.

Mary, S. (2009). A Textbook of the Nursing care. New York: Allied Press.

Nancy, M. & Charles, B. (2006). Care of Patients: A Nursing Perspective. New Jersey: Freeman Press.

White, P. & John, F. (2010). The Emerging Trends in Nursing. Washington DC: Medical Books.