Case Study and Care Plan

HPI

A 52-year-oldIrish American male is discharged from the hospital.He was hospitalized for four days after astent placement, following admission fromthe emergency room with angina symptoms. This patient presentedto the emergency roomwith four hours of crushing chest pain. He wasshort of breath withexertion anddiaphoretic. The patient thought he washaving a heart attack and was afraid to come to the hospital. Thesymptoms lasted for four days before the patient sought help. The patient had been sufferingfrom similarsymptoms for thepast six months but thought that he just out of shape. It was worseupon admission to the hospital.Prior to this,

the symptoms disappeared with rest.

Hissymptoms were relieved in the emergency department with medication andhe was transferred tothe cardiac floor forcatheterization.

The patient’s symptoms were highly debilitating uponhis admissionto the emergency department.

 

Prior to his admission to the hospital for this event, the patient was not very active because of his angina symptoms. The pain that he hadwas substernal and crushing and radiated to his neck and jaw. Hissymptoms resolve with rest only. He has not sought any therapeutic maneuvers.

 

He iscurrently asymptomatic and is here for a follow-up visit from his hospitalization to discuss his risk factors. The patientis still concernedthat he may have other episodes of angina, even after the stentplacement.

 

PMH

The patient has not sought care for his problems in the past. He had been treated for hypertension and high cholesterol in the past but stopped medication on his own.Besides that, he has had no othersignificant illnesses.

He was hospitalized for acholecysectomyten years ago.

This patient had a baselineEKG at his doctor’s officewhen he wasfirst prescribed his blood pressure medication. Otherwise he’s hadno other investigations forheart diseasebesides his cholesterol levels checks.

 

Results of LaboratoryInvestigationsFollowingHospitalization

Total cholesterol – 210

 

LDL- 200

 

HDL- 25

 

Triglycerides– 250

 

Fasting bloodsugar – 140

 

HgbA1c – 7.5

 

CXR – hyperinflation of the lungs – no infiltrate

 

EKG – no change from baseline.

Risk Factors:

•      High blood pressure

 

•      Hypercholesterolemia

 

•      Type 2 diabetes

 

•      Android obesity

 

•      Cigarette smoker

 

•      Positivefamilyhistory

Past surgicalhistory of Cholecysectomy, almost 10 years agewithout any complications.

ROS

 

Review of systems is otherwise negative

DISCHARGEMEDICATIONS

Tenormin XL50 mg daily Lipitor 10 mg daily Glucophage– 500mg BID BabyASAdaily

 

Patient is now compliantwith the prescribed regimen, but wasn’t in the past. The medicines were prescribed bythe physicianwho discharged him fromthe coronary care unit.

 

ALLERGIES/REACTIONS

Patient has no known drugallergies

SOCIALHISTORY

The patient is a high school graduate and a licensed carpenter andis anxious to get back to work because of finances. His income is around $50,000.00 per year. Hiswife is currently disabled

with uncontrolled type 2 diabetes. The patient hasdisruptedself-efficacy because he is not sure whether hecan care for his wife, who needs his help, now that he is sick. They live paycheck to paycheck and cannot afford a vacation.They have three grown-up childrenwhohave left home and do not live in the area.The patient has lived in thesamecity all his life. He does not participate insports or any other physical activity. Thestreets of hisneighborhoodare not safe for exercising; the crime rate is high. Thereis little community socialization and most people areat

the poverty level.

He is thesolebreadwinner in the family. Hisstress level is very high because of the impending bills that he needs to pay while he is not able towork. He believes that a man should be able to care for his family and be strong enoughnot to suffer from any illnesses himself.

The patient and hiswife live in a one-bedroom apartment in an inner city, quiteisolated fromtheir community. They do not have any relatives living in the area nor dothey socialize with neighbors. He has little emotional or socialsupport.He is stressed most of the time and is now suffering from depressive symptomssuchas sleeping excessively and over eating.

This patient has health insurance through the union to which he belongs, but it does not offer complete coverage of all his prescriptionmedications.Though he goes to a clinic that is associatedwith the hospital, he does not alwayssee the same primary care provider. HABITS

•      Diet Habits

 

The patient usually eats one large meala day afterwork.Heskipsbreakfastmostofthetimes and eats fast food for lunch.He eats fewfruits and vegetables; mostly pasta andmeat at home.

He feels that he got all the exercise he needed whenhe was a young man, and the exercise he gets as a carpenter now issufficient to keep him healthy.

 

Smoking: Hesmokes 1 pack per day from the past 30years

 

 

Extremities, Including Pulses:

Decreased pedal pulses BL with lower leg edema from ankle to mid calf. Neurologic: Not examined

EKG: No change from baseline

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