care plan

Patient’s information:

86-year-old female with history of A fibrillation on Eliquis, Hypertension, Heart failure presenting to the ED for evaluation in increasing weight of 7lbs over the last 2 week with an increase orthopnea, intermittent dyspnea and fatigue over the last several days. Her daughter who notices the new findings contacted the health care provider. Upon arrival, patient endorses the above symptoms along with non- productive cough, occasional tightness. She states she sleeps with pillow at home. She denies recent illness, fever, chill, vomiting, abdominal pain, diarrhea, constipation, blood in her urine or stool. She is vaccinated for covid-19 with her booster administration.

Diagnosis: Hypertension