I have attached a rubric to this. And the diagnosis I would like to use is Heart failure, which can be treated with diurectics such as Lasix

Patient is a 72 year old male here today for evaluation, and presents as a new patient to the clinic.  Patient has a history of Class I Heart Failure with PMH of Hypertension, Hyperlipidemia, and MI 3 years ago with 2 stents placed and Type 2 Diabetes Mellitus. His blood sugars run around 200 average;  Patient has smoked cigarettes since age 15, and has smoked 1 1/2 packs per day.  He has been on short acting Beta Agonist with minimal relief.  He states he has dyspnea with exertion.  He had a pulmonologist, and he underwent a Pulmonary Function test 2 years ago.   He states he has a chronic cough, moist and notes he has a hard time eating with his breathing.  Staff is able to obtain some records from the last Pulmonary Function test that reveal his FEV 1 was 77%;  He notes he cannot complete all the activities during the day without becoming very short of breath.   He is retired from Steel Mill in 2005;  He is allergic to codeine. He has also noted new swelling in his feet for about the last month or so, especially when he has been more active.  His current medications include: 

Ventolin HFA, 180 mcg, 2 puffs q4-6 hours;

Metoprolol 50 mg bid

LIsinopril 5 mg daily

Metformin 500 mg bid

Plavix 75 mg daily

He lives with his wife who is 70 yrs old and is in stable health and is a retired school teacher.  They live in Rural area of Ohio.  The live off of his Pension from the Mill and her pension from teaching.  They have 2 grown children who live out of state but check in on the parents occasionally.

 

 

 

(Case Study Format:  

Here is a “general” format;

Title page/Page numbers

Case Presentation

Pathophysiology of the (illness )

Your Physical  Assessment -What are you going to assess and why

Differential Diagnosis- what could it be,  Evidence Based Practice -Rationale, support with EBP

Cultural Perspectives

Health Promotion – what would you teach the patient? 

Treatments- both pharmacological and non pharmacological

(Include CYP 450 system)

What tests, screenings might you consider

What is your Plan of care, when would you have them f/u with provider and why?

References 3-5-  All these items – you need to support with Evidence Based Practice, such as for example, Non pharmacological interventions- where did you obtain your info, citation for the source;  any tests, any of the above items, support your rationale with Evidence Based Practice.