[Institution Title]
Patient Initials: Not Applicable Age: 52 yrs. old Sex: Male
Subjective Data:
HPI (History of Present Illness): The patient revealed during the interview that he had been suffering from severe and excruciating chest pain that gradually radiates to his neck. He had been experiencing the symptoms for four days prior to medical consultation. Patient feared that despite the stent placement, he was still experiencing angina symptoms. Patient revealed that the symptoms had appeared six months ago.
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations): Prior to hospitalization patient is not under any kind of medication. However, patient should have been taking medication for his hypertension and cholesterol problem which had been diagnosed earlier. Patient admitted to have undergone a cholecystectomy ten years ago. Patient had no known allergy.
Significant Family History: Patient’s wife is diagnosed with uncontrolled Type 2 Diabetes Mellitus. However, those directly related to patient had history of hypertension. This is particularly true for patient’s two brothers who were diagnosed and treated for hypertension and type 2 diabetes mellitus during their forties. Patient’s father died from heart problem while his mother died from breast cancer.
Social/Personal History (occupation, lifestyle—diet, exercise, substance use): Patient used to work as a carpenter before he took some time off from work to care for his wife who is also sick with uncontrolled type 2 diabetes mellitus. Patient does not engage in any physical activities claiming that his neighborhood is not conducive walks or jogging or biking because of the high incidence of criminality. Patient also does not eat breakfast, used to eat lunch hurriedly because of work. It is only at night that he is able to have a hearty meal. Patient also smoke cigarette consuming 1 pack of cigarette a day for the last 30 years. Overall, patient has a sedentary lifestyle.
Description of Client’s Support System: Patient has a very weak support system. However, this is self-brought. Patient refuses to ask his children’s helping terms of finances and assisting him to care for their mother. The only support system available to the patient is his wife who is also unable to support him because of the symptoms of her type 2 diabetes mellitus.
Behavioral or Nonverbal Messages: Patient verbalizes that his refusal to seek the help of his children is because he believes that it is the man’s obligation to provide and care for his wife. Patient also practices self-prescription and self-diagnosis.
Objective Data:
Vital Signs including BMI: Patient’s pulse rate, respiratory rate and temperature are all normal. However, patient’s BP is very high at 160/92. BMI computation also revealed that patient is obese after computing his BMI at 31.6 .
Physical Assessment Findings: After conducting ROS, only two findings were found abnormal. The first refers to patient’s abdominal measurement. The patient’s abdominal measurement of WC=44 is classified as obese. The second was abnormal heart sound heard from the right side after auscultation.
Lab Tests and Results: Patient’s lab test shows very high cholesterol level. Patient’s blood sugar level was also elevated. The patient’s blood glucose level is only normal if it was taken two hours after the patient has eaten anything. Nevertheless, for someone with an existing medical condition or heart problem, it should even be lower than 175.
After experiencing the symptoms and considering the condition of his wife, the patient was more receptive of the treatment and health education this time. In fact, patient agreed to take his medication according to physician’s order.
ICD-9 Diagnoses/Client Problems:
According to ICD-9 patient shows signs of malignant essential hypertension classified as 401.0 and family-history Type 2 diabetes mellitus classified as Z83.3 under the ICD-9 diagnosis .
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
References
Centers for Medicare & Medicaid Services. (2014, November 6). Centers for Medicare & Medicaid Services Website. Retrieved from 2014: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html?redirect=/ICD9ProviderDiagnosticCodes/04_addendum.asp
National Health, Lungs and Blood Institute. (2014, November 5). Aim for a Healthy Weight. Retrieved from National Health, Lungs and Blood Institute Website: http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
