Summary of history and visitPt being seen today for shortness of breath with activity. Pt has history of MI and Htn and has been noncompliant for six months. The shortness of breath is resolved at rest and sometimes wakes her up at night. Pt uses pillows to relieve symptoms. Pt is here today for a refill of home medications. Pt also has leg swelling as well. Pt has also been feeling lightheaded going up stairs which resolves with rest.Differential diagnosisCongestive heart failure (ICD-10: I50.21) Heart failure (HF; also commonly called congestive heart failure [CHF], is a progressive clinical syndrome, in which the heart fails to pump a sufficient supply of blood to the body due to a functional or structural disorder (Schub & Kornusky, 2016). Signs and symptoms of chf include fatigue, dyspnea, and fluid retention (Schub & Kornusky, 2016). The rationale for this diagnosis is BJ’s symptoms of shortness of breath with activity, and leg swelling.Acute renal failure (ICD-10: N17.9) Acute renal failure (ARF; more commonly referred to as acute kidney injury [AKI]) is a progressive but often reversible deterioration of kidney function that develops during a period of hours to days (Schub & March, 2016). The resulting inability of the kidneys to filter waste products from the blood can result in electrolyte imbalances, metabolic disturbances, and fluid imbalances (Schub & March, 2016).
You've reached the end of your free preview.
Want to read all 3 pages?
- Fall '16
- shortness of breath, statin therapy, CINAHL Nursing Guide, Schub, unrecognized myocardial infarction