Nu636anticoagulantpeerresponse#2

Subjective:

CC: 77-year-old white male presents to the office complaining of feeling dizzy, short of breath, easily fatigued and having a sensation of his heart â€˜skipping beatsâ€™ for three days

HPI: 77-year-old white male experiencing dizziness, shortness of breath, fatigue, and sensation of heart skipping beats for the past 3 days. Pt reports having the same symptoms numerous times over the last year or so, but they only lasted for about a day.

PMH: Type II Diabetes Mellitus (diagnosed 20 years ago, on Metformin 1000mg PO daily), Hypertension (diagnosed 15 years ago, on Lisinopril 20mg PO daily)

Medications: Lisinopril 20mg PO daily, Metformin 1000mg PO daily

ROS:

RESPIRATORY: Reports shortness of breath

CARDIOVASCULAR: Reports a sensation of heart skipping beats

NEURO: Feeling dizzy

Objective:

Vitals: BP 172/100, HR 123 irregularly irregular, RR 20

ROS:

RESPIRATORY: Clear to auscultation

CARDIOVASCULAR: Irregular

INTEGUMENTARY: Warm, pale with a slight gray cast

Assessment:

Irregular Heart Rhythm/Possible Atrial Fibrillation/Flutter
Uncontrolled Hypertension
Type II Diabetes Mellitus

Plan:

Therapeutics:

-The first priority for a symptomatic pt with tachycardia is to diagnose and treat the patientâ€™s irregular rhythm. Obtain 12-lead EKG STAT. Depending on the results, pt may require immediate cardioversion. Pharmaceutical cardioversion is the preferred method when diagnosed within 7 days. Pt will likely require admission to the hospital for cardioversion and prolonged cardiac monitoring (Arcangelo et al., 2022).

-IV diltiazem, verapamil, or beta blockers are ideal for patients with normal LV systolic function (LVEF > 40%). These medications are chosen over Digoxin, as they have a more rapid onset (Arcangelo et al., 2022)

-I would administer Metoprolol 5mg IV once now and PO daily to follow. Beta blockers reduce heart rate, blood pressure, myocardial contractility, oxygen consumption in the myocardium, and cardiac output (Arcangelo et al., 2022).

– I would order the following lab test: CBC, BMP, Thyroid function tests, INR, PT/PTT, and Digoxin levels (Arcangelo et al., 2022).

-The patient should also be started on anticoagulant therapy, as atrial fibrillation and flutter increase risk for blood clot formation. Warfarin, apixaban, dabigatran, endoxaban, or rivaroxaban for a minimum of 3 weeks or TEE is recommended (Arcangelo et al., 2022).

Educational:

–Educate pt and support persons on new medications.

-Educate pt and support persons on risks of poorly controlled hypertension and the importance of seeking care when concerning symptoms arise.

-Instruct pt to take daily weights and advise MD of any increase by 2 or more lbs (Arcangelo et al., 2022).

-Educate pt on bleeding risks while being on blood thinners. Pt should be cautious with falls, sharp objects, razors, etc. Avoid taking NSAIDs. Pt will also need to be scheduled for regular blood tests to assess clotting.

– The patient needs to learn how to take their own blood pressure and pulse measurements, interpret them, and recognize and react to symptoms of hypotension, such as lightheadedness, chest pain, shortness of breath, peripheral edema, or palpitations (Arcangelo et al., 2022).

Collaboration/Consultation:

-Consult Cardiology

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