CARDIAC DDA

Bio data.
Mrs. Short, 74 years old, Caucasian female.
Married.

CC: Shortness of breath, cough and fatigue

HPI: with h/o of Hypertension and Rheumatic Arthritis.

ROS: +fatigue, +SOB on exertion, +palpitations, +edema, +joint pain in hands

PMH: HTN, RA – last visit with rheumatologist was “years ago” because she did not want to
take DMARDs, GERD, osteopenia, menopause.

SH: 3 glass of wine daily

FH: Father side of family with Type 2 Diabetes Mellitus and Hypertension.

Meds: metoprolol XL 50mg qd, ASA 81mg qd, Calcium 1000mg daily, Pepcid 20mg qd,
Tylenol as needed for pain
Physical Exam:
VS: BP 142/90, P90, R18, SPO2 98% on RA, height 60in, weight 150lbs, BMI 29.3 (up 7lbs in 6
mos)
Ext: 1+ BLE edema, pedal pulses 2+ bilateral, no calf tenderness,
MS: small joint deformities and synovitis present in bilateral hands. Slight tenderness in joints of
fingers, strength 5/5 in bilateral hands, ROM slightly limited in fingers.

MEDICAL DIAGNOSIS WITH ICD 10 CODES

 R06.02 Shortness of Breath

 R05 Cough
 R53.83 Fatigue
 I10 HTN
 M06.9 Rheumatoid Arthritis
 R00.2 Palpitations
 R60.9 Edema
 F10.20 ETOH/Alcohol Dependence
 Z83.3 Family HX of T2DM
 Z84.89 Family HX of HTN
 E66.9 Obese
 R01.2 S3 gallop
DIFFERENTAL DIAGNOSIS WITH ICD 10 CODES.

Rule out #1 I24.9 Acute Coronary Syndrome

Rule out #2 I42.0 Dilated Cardiomyopathy
Rule out #3 I34.0 Mitral Regurgitation
Rule out #4 428.0 Congestive Heart Failure
Rule out #5 J18.9 Pneumonia
Rule out #6 J45.909 Asthma
Rule out #7 I26 Pulmonary embolism

Nursing Diagnosis/Health Maintenance or Social issue ICD -10 codes.

R6889 Activity intolerance
RO6.89 Ineffective breathing pattern
I50.9 Decreased cardiac output
M25.5 Acute joint pain
Z78.9 Ineffective health maintenance
R45.81 Chronic low self esteem
E66.3 Obesity
E87.7 Excess fluid volume
R53 Fatigue
Z55.0 Deficient Knowledge.

Initial Treatment Plan

Diagnostics/Laboratories
ECG, CXR, thyroid function test, troponin, BNP, echocardiography, Full hemogram,
Antinuclear Antibodies test, Streptolysin O titres, CRP.Calcitonin, ESR, Spirometry, Blood
culture, Kidney function Tests, UECs, Liver function tests.

Initial prescriptions, referrals, non-pharmacological medical treatments needed;

 Admit the patient and refer if necessary i.e. the care they need cannot be offered in the
facility.
 Ensure rest with limbs elevated to enhance venous return and reduce leg swelling.
 Oxygen for shortness of breath.
 Diuretics (loop diuretics) paired with patient’s metoprolol; furosemide or thiazides
depending with the degree of fluid overload.
  Vasodilators- nitroglycerin, captopril
 Angiotensin 11 receptor antagonists; Losartan.
 Inotropes; Digoxin, Digitalis
 Vasopressors; epinephrine, vasopressin
 Disease modifying anti rheumatic drug (DMARDS); methotrexate, hydro chloroquine.
 Analgesics; Tylenol

Nursing Interventions / Education

 Restrict fluid intake to 1-1.5Litres per day
 Restrict salt intake
 Diet modification; low caloric intake.
 Limit alcohol intake to 1 drink per day
 Educate patient on following a continuous medication regimen recommended by the
doctor since rheumatoid arthritis is a lifelong disease.
 Incorporate physiotherapy in the patient’s treatment to improve range of motion.
 Check weight daily and record for easy tracking.
 Link the patient to a support group to enhance coping strategies while living with these
lifelong illnesses.
 Educate the patient on symptoms to look out for that will warrant return to hospital such
as shortness of breath, chest pain, palpitations, fatigue, increased swelling in the legs.
 Give the patient a return date after a week on discharge to monitor progress.