MSN 610 Diagnostic Reasoning and Advanced Physical Assessment Case Study 4A

A 68 year- old female returns for a follow up at the primary care clinic. She has a known history of Paroxysmal Atrial Fibrillation. She states she has felt her heart “go out of rhythm” several times since her last appointment 3 months ago. She has not seen her cardiologist in over a year. The irregular rhythm has been occurring 2-3 x/week for the last 2 months lasting 1-5 minutes., PMH: Paroxysmal A Fib, DM II, HTN, CHF Medications: Coreg 25 mg BID Metformin 1000 mg BID Sacubitril/Valsartan 49/51 mg BID Abixiban 5 mg BID Diltizem ER 120 mg BID Family History: Father deceased at age 80 with CVA Mother deceased at age 78 with HTN, DM II, Glaucoma, Hypothyroidism 1 Sister living at age 65 with CAD s/p CABG Social History: Lives alone in a condo. Retired from teaching school. She denies ever smoking or use of alcohol. She admits to consuming “iced tea” all day long. Her diet consists of cereal and fruit for breakfast, a sandwich or salad for lunch and/or dinner. ROS: General: Denies weight gain or loss, fatigue, fever or chills Cardiac: Denies chest pain or dyspnea, Admits to palpitations as described in HPI, Also admits to increased ankle swelling Resp: Denies cough, wheezing, PND Heme: Denies acute bleeding or melena but admits to frequent bruising Physical Exam Ht: 5’5 Weight: 165 lb BP: 118/72 HR: Irregular at 100 bpm Resp: 18 O2Sat: 96% General: Well groomed, Alert, Oriented, Cooperative, 68 yo female who appears her stated age in NAD Neck: Mild JVD, Trachea midline, No Thyromegaly, No lymphadenopathy, Carotid Pulse Irregular COR: Irregular S1S2 with early systolic Murmur (III/VI) at 4th ICS MCL Lungs: CTA with equal bilateral expansion. No abnormal tactile fremitus. No wheezing or rhonchi heard. Fine bibasilar rales present Extremities: + 2 ankle edema bilaterally, Radial pulses equal @ +2, Pedal Pulses equal @ +1 Her EKG rhythm strip is: This study source was downloaded by from CourseH on :07:46 GMT -06:00 1) Discuss the problematic findings with this case. What are your diagnoses?  Palpitation present  Ankle edema  Irregular pulse  Irregular S1S2  Early murmur present  Fine bibasilar rales present  Pedal pulses 1+ bilaterally  Frequent bruising  Lives alone  Frequent iced tea consumption  Mild JVD  Frequent bruising  Poor diet  Not seen cardiologist in over a year  Irregular rhythm 2-3/week for past 2 months lasting 1-5 minutes  Lives alone Diagnoses  Paroxysmal A fib  HTN  CHF  Tachycardia  DM II 2) What is the difference between Persistent, Paroxysmal and Permanent A fib?  Persistent A fib- irregular heart rhythm lasting longer than 7 days, will not resolve on own and will require treatment.  Paroxysmal A fib- heart rhythm returns to normal on our own, or with intervention with 7 days of onset. Unpredictable may have a few a year or daily. Can turn into a permanent form of A fib.  Permanent A fib- irregular lasts indefinitely. Patient and practitioner agree to no longer attempt to return to regular to regular rhythm. What are the Symptoms of Atrial Fibrillation (AFib or AF)? (2016). Www.Heart.Org. 3) What is this patient’s CHADsVASC Score and what does this mean?  5  CHAdsVASC Score estimates thromboembolic risk in patients with A fib. Faganello, G., Barbati, G., Russo, G., Scagnetto, A., Mazzone, C., Mottolese, B. D. ’Agat., Zaccari, M., Sinagra, G., Lenarda, A. D., & Cioffi, G. (2020). CHA2DS2-VASc Score Predicts Adverse Outcome in Patients with Simple Congenital Heart Disease Regardless of Cardiac Rhythm. Pediatric Cardiology, 41(5), 1051–1057. 4) How would you code this visit?  High risk established patient- 99215 Hermansen, C. L., & Jackson, J. (2014). When Is It Right to Code 99215? Family Practice Management, 21(6), 12– 16. This study source was downloaded by from CourseH on :07:46