Assessing The Heart

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Post 1

CHIEF COMPLAINT: Shortness of Breath and cough

Subjective:  Pt presents with complaints of shortness of breath and productive cough.  Pt relates he is coughing up thick green sputum with occasional bloody sputum. Pt relates that he has increased shortness of breath with walking.  Patient relates that he is also short of breath at rest. Pt also relates that he has had some chills and sweats and felt like he may have a fever.  He states that he has taken Tylenol for those symptoms.

Objective: Temperature 100.9, Respiratory rate 20, Heart rate 82, Blood pressure right arm 128/70, Oxygen saturation 89% on room air, Weight 210 pounds, EKG shows normal sinus rhythm, Chest radiograph

Assessment:  Skin is warm and moist. Thorax is symmetrical with diminished breath sounds with rales and expiratory wheezes throughout, negative for rhonchi. Wet productive cough noted during exam. Heart is regular sinus rhythm with rate of 82. Good S1, S2; negative S3 or S4 and negative for murmur. Abdomen protuberant with normoactive bowel sounds auscultated in all four quadrants. No pedal edema noted. 2+ dorsalis pedis pulses bilaterally. Neurologic: Patient is awake, alert and oriented to person, place and time. Chest radiograph shows infiltrate in the right middle lobe.

Priority diagnosis includes 1. Pneumonia 2. Myocardial Infarction 3. Pulmonary embolism   4. Congestive Heart Failure 5. Asthma

1. Pneumonia: The patient presents with productive cough and shortness of breath with exertion.  Patient has elevated temperature and low oxygen saturations along with diminished breath sounds, rales and expiratory wheezes which are all consistent symptoms with community acquired pneumonia. (Lynn, 2017).  Chest radiograph shows right middle lobe infiltrate which is also consistent with pneumonia. (Kaysin and Viera, 2016).

2. Myocardial Infarction: The patient presents with shortness of breath and low oxygen saturations.  Pt states that his shortness of breath is worse with exertion but is present at rest also.  Dyspnea is a frequent associated symptom with MI. (Lawesson, Thylen, Ericsson, Swahn, Isaksson and Angerud, 2018). The patient did have an EKG completed that revealed a normal sinus rhythm at a rate of 80 with no obvious signs of ectopy.  Evaluation of troponin level would assist in ruling out MI as a diagnosis for this patient. (Berliner, Schneider, Welte and Bauersachs, 2016).

3. Pulmonary Embolism: Dyspnea is the primary symptom for patients with PE. (Garcia-Sanz, Pena-Alvarez, Lopez-Landeiro, Bermo-Dominguez, Fonturbel and Gonzalex-Barcala, 2014). Onset of dyspnea with PE is typically sudden and further history for this patient related to onset of symptoms.  Evaluation of any extremity pain and swelling, D-dimer or chest angiography would also assist in determining if this was a more likely diagnosis. (Berliner, Schneider, Welte and Bauersachs, 2016).

4. Congestive Heart Failure: Dyspnea is also a common symptom with congestive heart failure.  Fatigue, diminished exercise tolerance and fluid retention are also common symptoms of CHF. (Berliner, Schneider, Welte and Bauersachs, 2016). The patient has rales noted upon auscultation which could be consistent with congestive heart failure however coupled with the remainder of the exam including productive cough with thick green sputum and fever, CHF would not be the primary diagnosis. Further evaluation of extremities of abdomen and extremities for signs of fluid retention would be indicated as well as labs such as BNP.

5. Asthma: The patient has expiratory wheezes and shortness of breath which are both consistent with asthma; however the patient also has fever and productive cough which are not consistent asthma symptoms. (Huether and McCance, 2017).

Plan: Not indicated

References

Arcangelo, V. P., Peterson, A. M., Wilbur, V. & Reinhold, J. A.  (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.