GEN/CC: I can barely fit into any of my shoes my ankles are all swollen and I am having difficulty breathing.
HPI: EO is a 72 year old Caucasian female who was on holiday with her husband from Canada presents in the emergency room with a 3 weeks history of progressively increasing breathlessness, orthopnea and ankle swelling. The breathlessness comes on with minimal exertion and she denies a history of chest pain. Her husband forced her to come to the emergency room because she had difficulty breathing while sitting down. She sleeps with 3 pillows and she alluded to waking up in the middle of the night sometimes gasping for breath. The ankle swelling started spontaneously but has worsened over the past 3 weeks. She no longer wears her regular shoes, thus she now resorts to wearing sandals. No associated history of trauma, no past history of arthritis.
She has a past history of MI 3 years ago but could not give details of what really happened.
High blood pressure x 10 years.-well controlled.
Insomnia- patient not sure of how long it started.
PSH: Nil on file
Metoprolol tartrate 25mg by mouth bid
Pravastatin 40mg by mouth once a day
Lisinopril 10mg by mouth once a day
Furosemide20mg po once daily.
Naproxen 220mg by mouth once a day as needed.
Immunization records up to date.
ALL: Penicillin x 20 years ago
SH: She is married with 2 children. Her husband is 78 year old retired sales man who likes to smoke indoors.
Past cigarette smoker who quit smoking immediately after her MI attack. They both consume alcohol.
She has adequate medical insurance on her trip. She does not like to cook and eats out occasionally when her husband is not cooking. She drinks 2 cups of coffee daily in the morning and i...
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... patients who consume so much alcohol.2,5 EO should be advice to reduce her alcohol consumption, limit her caffeine intake caffeine has been shown to cause insomnia and increase in heartbeat, get involve in more physical exercise to stay healthy, limit her eating out since most restaurant food are prepared from process package food which has been shown to contain a lot of salt. EO will benefit from incorporating the dash diet eating plan into her diet. The DASH diet is a diet rich in grains, vegetables, fruits, low-fat or non- dairy foods, 2 or more serving of meat, poultry, fish, 4 to 5 servings of nuts, seeds, and legumes per week based on a 2000 calorie diet per day while limiting the consumptions of fat and sweets. DASH diet has been shown to lower LDL and helps control weight loss and may be beneficial as an adjunctive therapy for patients with symptomatic HF.
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