Client History & Assessment Data

Mr Sullivan: Adult CAD, MI, HF


Mr. Sullivan, a 79 y/o current 1 pk/day smoker for over 50 yrs, has the diagnoses of Hypertension (HTN), Hyperlipidemia (HLD) & a relative new diagnosis of Coronary Artery Disease (CAD) having had a Non ST Elevation Myocardial Infarction (NSTEMI) 4 weeks ago.  He presents to the Health Clinic today for a routine follow-up following his MI.


He tells the Health Care Provider that he is short of breath (SOB) lately, has been sleeping in the recliner for the past week as he would wake up when sleeping in his bed, with air hunger.  He tells you that he now gets SOB walking up the driveway after retrieving his newspaper in the morning. He also tells you that his socks are quite tight around his ankles & his shoes seem too small.


He has no medication or food allergies. Home medications include: EC ASA 81 mg daily, clopidogrel 75 mg daily, metoprolol tartrate 50 mg q 12 hr, lisinopril 5 mg daily, atorvastatin 40 mg hs, and NTG SL prn chest pain.


Vital Signs:  BP 156/88, HR 110, RR 26, POX 90% RA, Temp 97.8.  Weight 89 kg today; on hospital discharge weight documented at 81 kg.

Physical Assessment:  Neuro A & O x3; Neck +JVD to the ear lobe; Lungs crackles throughout; Heart Sounds regular, tachycardic, S3, S1,S2, no murmurs appreciated; Abd soft, nontender, non-distended, bowel sounds +; Extremities PP+, 3+ pitting pedal edema.


Response to the Questions:

  1. Explain the pathophysiology r/t to the top 2 priority diagnoses.
  2. What Client History & Assessment Data help support your priority diagnoses?
  3. Do all the clients medical diagnoses link together?  If so how?
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