Analysis Of Cardiology Case Study And Plan Of Care

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Analysis of Cardiology Case Study and Plan of Care Subjective Data The patient is a fifty-two-year-old male of Irish American descent with initials A.B. who presents to the clinic for a follow-up visit to discuss key risk factors following an admission to the hospital where he underwent cardiac catheterization and the placement of a stent. Chief Complaint (CC) A.B. presented to the emergency department (ED) complaining of severe substernal chest pain that lasted for four hours and that he described as “crushing”. He reported that the pain radiated to his neck and jaw. Additionally, the patient was experiencing shortness of breath (SOB). History of Present Illness (HPI) The symptoms of severe chest pain are consistent with angina pectoris, which A.B. reported lasting for four days prior to his ED visit. While the severity of the angina pain worsened immediately before his hospital admission, A.B. had been experiencing symptoms of chest pain for the last six months, although the pain subsided upon resting. His symptoms also included shortness of breath and was diaphoretic, which the patient thought was indicative of a myocardial infarction. During his recent four-day admission to the hospital, the patient underwent a cardiac catheterization and a stent was placed. His symptoms of angina have prevented A.B. from keeping an active lifestyle and he is concerned that the angina pectoris episodes may reoccur despite the placement of the stent and being currently asymptomatic. Past Medical History (PMH) A.B’s past medical history includes hypertension (HTN) and hypercholesterolemia for which he was on medication before stopping them on his own accord. Also, the patient has diabetes mellitus type two (MDII or T2DM). He reports havin... ... middle of paper ... ...rtery with angina pectoris with documented spasm; I10, Essential (primary) hypertension; E78.0, Pure hypercholesterolemia; E11.9, Type 2 diabetes mellitus without complications; E66.9, Obesity, unspecified; Z72.0, Tobacco use; Z80.3, Family history of malignant neoplasm of breast; Z83.3, Family history of diabetes mellitus; Z82.49, Family history of ischemic heart disease and other diseases of the circulatory system; F33.9, Major depressive disorder, recurrent, unspecified. (Centers for Medicare and Medicaid Services, 2015). Advanced Practice Nursing Intervention Plan The plan of care for A.B. will be primarily based on education regarding his risk factors and how he can decrease the chance of suffering from another coronary event, such as angina pectoris, by following a lifestyle modification plan and strict medication adherence in order to manage his comorbidities.
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