Subjective Data: The patient is a 52-year-old male who presents with fatigue after being hospitalized for two weeks for stent placement.
Chief Complaint: The patient states that his heart has been “racing” (Case Study, n.d.).
History of Present Illness: The man is physically active. He had palpitations caused by exercise. Two days ago, the patient experienced shortness of breath on exertion and an elevated heart rate that did not decrease with rest. Smoked 15 pack/year for 20 years.
PMH/Medical/Surgical History: The man was diagnosed with rheumatic heart disease in childhood. The patient was diagnosed with hypertension 10 years ago and with hyperlipidemia 5 years ago. Post coronary stenting. The patient has been following a low cholesterol diet for the last two weeks.
Significant Family History: Non-contributory.
Social History: Non-contributory.
Vital Signs: BP -160/90; HR 146; RR 22; T 98.6 F; Wt. 254; Ht. 5’ 7”.
Physical Assessment Findings
HEENT: PERRLA, (-) JVDm mild arteriovenous nicking
Heart: irregularly irregular rate; murmurs and gallops are absent.
Abdomen: soft, non-tender with the presence of active bowel sounds.
Extremities/Pulses: no edema; pulses are normal.
Neurologic: A&O X3.
Laboratory and Diagnostic Test Results:
Na – 136
K – 4.5
Cl – 97
BUN – 20
Cr – 1.2
Total Chol – 240
Trig – 180
INR – 1.1
Chest Xray – Clear
ECG – Atrial Fibrillation, no P waves, variable R-R interval normal QRS
Atrial Fibrillation (148.91)
The first differential diagnosis for the patient is atrial fibrillation, which is an extremely prevalent sustained cardiac arrhythmia with the rate of prevalence approaching 2 percent (Camm et al., 2012). The condition is strongly associated with hypertension and coronary heart disease. According to Manolis et al. (2012), “hypertension per se increases the risk of atrial fibrillation by about two-fold” (p. 240). The patient has reported shortness of breath on exertion, which is associated with the disease. Other symptoms of the condition that are present in the patient include palpitations, light-headedness, and generalized weakness. Most importantly, ECG confirmed the diagnosis.
Heart Failure (428.9)
The second differential diagnosis for the patient is heart failure. According to the definition provided in ESC Guidelines for the diagnosis of the condition, heart failure is “an abnormality of cardiac structure or function leading to failure of the heart to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues” (McMurray et al., 2012). Abnormalities of heart rhythm, the underlying cardiac problem, elevated pressure, minor retinal abnormalities, and breathlessness among others are symptoms of the disease.
Myocardial Infarction (MI) (121.3)
MI is the third differential diagnosis for the patient. According to Gara et al. (2013). almost 30 percent of patients do not experience chest pain during the onset of MI; therefore, other symptoms present in the patient can be attributed to the disease.
Plan of Care
Novel oral anticoagulants are known to reduce stroke risk. Taking into consideration the fact that the patient does not fall in a low-risk category, he cannot be prescribed aspirin-clopidogrel combination therapy (Camm et al., 2012). Instead, it is recommended to treat the patient with 20 mg of rivaroxaban for 30 days to reduce stroke risk (Camm et al., 2012).
The man should be immediately hospitalized. The patient has to be treated with an ACE inhibitor, an MRA, and a beta-blocker in conjunction with a diuretic (McMurray et al., 2012).
Myocardial Infarction (MI)
Hospitalization is necessary. Given that the condition is associated with an extremely high morbidity rate, it is important to restore perfusion in a very rapid manner. Before starting the treatment, health care professionals have to distinguish between STEMI and NSTEMI and consider different pharmacological options. The use of oral ACE inhibitors is recommended.
Camm, J., Lip, G., Caterina, R., Savelieva, I., Atar, D., Hohnloser, S.,…Kirchhof, P. (2012). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation (developed with the contribution of the European Heart Rhythm Association). European Heart Journal, 33(21), 2719-2747.
Case Study. (n.d.).
Gara, P., Kusher, D., Lemos, J., Fang, J., Franklin, S., Krumholz, H.,… Woo, Y. (2013). 2013 ACCF/AHA Guideline for the management of ST-elevation myocardial infarction. Circulation, 127(1), 362-425.
Manolis, A., Rosei, E., Coca, A., Cifkova, R., Erdine, S., Kjeldsen, S.,…Mancia, G. (2012). Hypertension and atrial fibrillation: diagnostic approach, prevention, and treatment: Position paper of the Working Group ‘Hypertension Arrhythmias and Thrombosis’ of the European Society of Hypertension. Journal of Hypertension, 30(1), 239-252.
McMurray, J., Admmopoulos, S., Anker, S., Auricchio, A., Bohm, M., Dickstein, K.,…Zeiher, A. (2012). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 33(21), 1787-1847.