Running head: CARDIOLOGY CASE STUDY ANALYSIS AND CARE PLAN 1
Patient Initials: I.A. Age: 52 y/o Sex: Male Demographics: Irish American
Subjective Data:
Client Complaints:
Patient states “I am concerned that I still have chest pain even after the stent placement”
Chest pain
Shortness of breath with exertion
Diaphoresis
HPI (History of Present Illness):
Mr. I.A. is a 52 year old Irish American male with a past medical history of hypertension and
high cholesterol and a past surgical history of cholecystectomy. He is here today for a follow up
appointment having being discharged from the hospital four days ago following cardiac
catheterization with stent placement. Events leading to his prior hospitalization for cardiac
catheterization included an emergency room visit for crushing chest pain that lasted for four
hours as well as shortness of breath with exertion and diaphoresis that had been occurring for the
past six months with increasing severity. Patient described his chest pain at that time as
substernal, crushing, and radiating to the neck and jaw. He stated that the symptoms only
resolved with rest and had been occurring over the past six months. Patient received medication
in the emergency department before being transferred to the cardiac lab for catheterization.
During this visit, patient is asymptomatic but afraid that he might be having other episodes of
angina in spite of stent placement.
Past Medical History (Past Medical History—include current medications, any known
allergies, any history of surgery or hospitalizations):
Allergies: No known drug allergies
PMH: Hypertension
High cholesterol
Stable Angina
Cardiac catheterization with four-day hospitalization
PSH:
• Status post cardiac catheterization with stent placement
• Status post cholecystectomy (10 years ago) without complications
Current Medications:
• Tenormin XL 50 mg by mouth once a day, for angina and high blood pressure (Lewis et al,
2011))
• Lipitor 10 mg once a day by mouth, for cholesterol management (Lewis et al, 2011)
• Glucophage 500mg by mouth two times a day, for blood glucose control (Lewis et al, 2011)
• Baby acetylsalicylic acid (ASA or Aspirin) by mouth one tablet once a day (Lewis et al, 2011)
, CARDIOLOGY CASE STUDY ANALYSIS AND CARE PLAN 2
Significant Family History:
• Two older brothers being treated for high blood pressure and type 2 diabetes.
• Father deceased from heart disease.
• Mother deceased from breast cancer.
Social/Personal History: (occupation, lifestyle—diet, exercise, substance use)
Occupation: Patient is a high school graduate and a licensed carpenter.
Financial: The patient’s annual income is about $50,000 a year and he stated that he is the sole
bread winner of the family because his wife is currently disabled due to uncontrolled type 2
diabetes mellitus. Patient is anxious to get back to work because of finances and is provisionally
diagnosed with disrupted self-efficacy because he is unsure that he can care for his wife who
needs his help now that he is sick. They live paycheck to paycheck and cannot afford a vacation.
His stress level is very high because of the impending bills that he needs to pay while he is not
able to work. He believes that a man should be able to care for his family and be strong enough
not to suffer from any illnesses himself.
Social: Patient and his wife live in a one-bedroom apartment in an inner city that is isolated from
their community. They do not have any relatives living in the area nor do they socialize with
neighbors. He has little emotional or social support. He is stressed most of the time and is now
suffering from depressive symptoms such as sleeping excessively and over eating. They have
three grown-up children who have left home and do not live in the area. The patient has lived in
the same city all his life. There is little community socialization and most people residing in the
area are at poverty level. The patient has health insurance through the union to which he belongs,
but it does not offer complete coverage for all his prescription medications. Though he goes to a
clinic that is associated with the hospital, he does not always see the same primary care provider.
Lifestyle – diet, exercise, substance abuse:
• Diet
The patient usually eats one large meal a day after work. He skips breakfast most of the times
and eats fast food for lunch. He eats few fruits and vegetables; mostly pasta and meat at home.
• Exercise
The patient does not participate in sports or any other physical activity. He states that the streets
of his neighborhood are not safe for exercising because the crime rate is high. He feels that he
got all the exercise he needed when he was a young man, and the exercise he gets as a carpenter
now is sufficient to keep him healthy.
• Substance abuse
Patient I.A. is a cigarette smoker. He admits smoking 1 pack per day from the past 30 years. He
does not drink alcohol and he denies street drug use.
• Hobbies
Patient states he has no hobbies and he reads at home.
Description of Client’s Support System:
Patient I.A has minimal social and emotional support system. He lives with his disabled wife in a
one-bedroom apartment in an inner city that is isolated from their community. They do not have
any relatives living in the area nor do they socialize with neighbors. They have three grown-up
children who have left home and do not live in the area.
Patient Initials: I.A. Age: 52 y/o Sex: Male Demographics: Irish American
Subjective Data:
Client Complaints:
Patient states “I am concerned that I still have chest pain even after the stent placement”
Chest pain
Shortness of breath with exertion
Diaphoresis
HPI (History of Present Illness):
Mr. I.A. is a 52 year old Irish American male with a past medical history of hypertension and
high cholesterol and a past surgical history of cholecystectomy. He is here today for a follow up
appointment having being discharged from the hospital four days ago following cardiac
catheterization with stent placement. Events leading to his prior hospitalization for cardiac
catheterization included an emergency room visit for crushing chest pain that lasted for four
hours as well as shortness of breath with exertion and diaphoresis that had been occurring for the
past six months with increasing severity. Patient described his chest pain at that time as
substernal, crushing, and radiating to the neck and jaw. He stated that the symptoms only
resolved with rest and had been occurring over the past six months. Patient received medication
in the emergency department before being transferred to the cardiac lab for catheterization.
During this visit, patient is asymptomatic but afraid that he might be having other episodes of
angina in spite of stent placement.
Past Medical History (Past Medical History—include current medications, any known
allergies, any history of surgery or hospitalizations):
Allergies: No known drug allergies
PMH: Hypertension
High cholesterol
Stable Angina
Cardiac catheterization with four-day hospitalization
PSH:
• Status post cardiac catheterization with stent placement
• Status post cholecystectomy (10 years ago) without complications
Current Medications:
• Tenormin XL 50 mg by mouth once a day, for angina and high blood pressure (Lewis et al,
2011))
• Lipitor 10 mg once a day by mouth, for cholesterol management (Lewis et al, 2011)
• Glucophage 500mg by mouth two times a day, for blood glucose control (Lewis et al, 2011)
• Baby acetylsalicylic acid (ASA or Aspirin) by mouth one tablet once a day (Lewis et al, 2011)
, CARDIOLOGY CASE STUDY ANALYSIS AND CARE PLAN 2
Significant Family History:
• Two older brothers being treated for high blood pressure and type 2 diabetes.
• Father deceased from heart disease.
• Mother deceased from breast cancer.
Social/Personal History: (occupation, lifestyle—diet, exercise, substance use)
Occupation: Patient is a high school graduate and a licensed carpenter.
Financial: The patient’s annual income is about $50,000 a year and he stated that he is the sole
bread winner of the family because his wife is currently disabled due to uncontrolled type 2
diabetes mellitus. Patient is anxious to get back to work because of finances and is provisionally
diagnosed with disrupted self-efficacy because he is unsure that he can care for his wife who
needs his help now that he is sick. They live paycheck to paycheck and cannot afford a vacation.
His stress level is very high because of the impending bills that he needs to pay while he is not
able to work. He believes that a man should be able to care for his family and be strong enough
not to suffer from any illnesses himself.
Social: Patient and his wife live in a one-bedroom apartment in an inner city that is isolated from
their community. They do not have any relatives living in the area nor do they socialize with
neighbors. He has little emotional or social support. He is stressed most of the time and is now
suffering from depressive symptoms such as sleeping excessively and over eating. They have
three grown-up children who have left home and do not live in the area. The patient has lived in
the same city all his life. There is little community socialization and most people residing in the
area are at poverty level. The patient has health insurance through the union to which he belongs,
but it does not offer complete coverage for all his prescription medications. Though he goes to a
clinic that is associated with the hospital, he does not always see the same primary care provider.
Lifestyle – diet, exercise, substance abuse:
• Diet
The patient usually eats one large meal a day after work. He skips breakfast most of the times
and eats fast food for lunch. He eats few fruits and vegetables; mostly pasta and meat at home.
• Exercise
The patient does not participate in sports or any other physical activity. He states that the streets
of his neighborhood are not safe for exercising because the crime rate is high. He feels that he
got all the exercise he needed when he was a young man, and the exercise he gets as a carpenter
now is sufficient to keep him healthy.
• Substance abuse
Patient I.A. is a cigarette smoker. He admits smoking 1 pack per day from the past 30 years. He
does not drink alcohol and he denies street drug use.
• Hobbies
Patient states he has no hobbies and he reads at home.
Description of Client’s Support System:
Patient I.A has minimal social and emotional support system. He lives with his disabled wife in a
one-bedroom apartment in an inner city that is isolated from their community. They do not have
any relatives living in the area nor do they socialize with neighbors. They have three grown-up
children who have left home and do not live in the area.
