History of hypertension for 10 years, hyperlipidemia for 5 year, status post stent placement 2 weeks ago, and rheumatic heart disease (mitral valve) as a child. He reports adhering to a low cholesterol low fat diet for the last 2 years.
Stent placement 2 weeks ago.
Social: Smoked 15 pack/year X 20 years. Quit 5 years ago.
Otherwise negative.
BP 160/90 (clinic visit 2 months ago 155/85) HR 146, RR 22, T 98.6 F, Wt 254, Ht 5’ 7”
Gen: Well developed male in moderate distress. HEENT: PERRLA, (-) JVDm mild AV nicking. Cardio: Rate irregularly irregular, no murmurs or gallops. Chest: Clear to auscultation. Abd: soft, non-tender, active bowel sounds. GU: Deferred. Rectal: Normal. EXT: No edema, normal pulses throughout. NEURO: A&O X3.
Week 1:
Cardiovascular
Clinical Case
Patient Setting:
52 year old Irish American Male that was hospitalized 2 weeks ago for a stent placement. Presenting to
your clinic today for follow up as he has not felt well. He sates he has been lightheaded and
felt
palpitations of his heart. He has also had shortness of breath the last 2 days.
HPI
Walks 2 miles daily and rides an exercise bicycle 3 times a week; has previously felt the palpitations
associated with exercise that usually went away with rest; 2 d
ays ago while washing dishes he began to
feel shortness of breath and felt that his heart was “racing”; He hoped the palpitations would go away
but they have continued and that is why he is here today.
PMH
History of hypertension for 10 years, hy
perlipidemia for 5 year, status post stent placement 2 weeks
ago, and rheumatic heart disease (mitral valve) as a child. He reports adhering to a low cholesterol low
fat diet for the last 2 years.
Past Surgical History
Stent placement 2 weeks ago.
Famil
y/Social History
Family: Noncontributary
Social: Smoked 15 pack
/year X 20 years. Quit 5 years ago.
Medication History
Lisinopril 20 mg PO QD
Furosemide 20 mg PO QD
Gemfibrozil 600 mg PO BID
Week 1: Cardiovascular Clinical Case
Patient Setting:
52 year old Irish American Male that was hospitalized 2 weeks ago for a stent placement. Presenting to
your clinic today for follow up as he has not felt well. He sates he has been lightheaded and felt
palpitations of his heart. He has also had shortness of breath the last 2 days.
HPI
Walks 2 miles daily and rides an exercise bicycle 3 times a week; has previously felt the palpitations
associated with exercise that usually went away with rest; 2 days ago while washing dishes he began to
feel shortness of breath and felt that his heart was “racing”; He hoped the palpitations would go away
but they have continued and that is why he is here today.
PMH
History of hypertension for 10 years, hyperlipidemia for 5 year, status post stent placement 2 weeks
ago, and rheumatic heart disease (mitral valve) as a child. He reports adhering to a low cholesterol low
fat diet for the last 2 years.
Past Surgical History
Stent placement 2 weeks ago.
Family/Social History
Family: Noncontributary
Social: Smoked 15 pack/year X 20 years. Quit 5 years ago.
Medication History
Lisinopril 20 mg PO QD
Furosemide 20 mg PO QD
Gemfibrozil 600 mg PO BID
malaperez2000
su_nsg6001_cardioclinicalcasenursing.docx
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