PAST MEDICAL/SURGICAL HISTORY:
Patient has a history of a myocardial infarction (MI, or also known as a heart attack) in 2004, she had a hip pinning in 2005, and a traumatic amputation of fingers on her left hand in 1974 from a lawnmower accident.
Pt lived on her own until 4-27-12 when her family found her lying on the floor in her home. Pts family brought her to live with them but pt continued to have episodes of falling and hitting her head. Pt was taken to the ER and given a Ct of the brain where all results turned up normal. After at least 5 more falls the pts family took her back to the hospital with complaints of chest pain and palpitations. Pt was more confused than ...view middle of the document...
2015, pg. 465)
Chronic Kidney Disease (CKD) stage 5 is the most severe stage of chronic kidney disease in which dialysis/transplant is initiated. It is an irreversible, progressive disease of the decrease of function in the kidneys preventing the patient from maintaining metabolic, fluid, and electrolyte balance (Hopper & Williams. 2015, pg. 855).
Myocardial Infarction (MI) is another term used for a heart attack. It is a medical emergency. During a heart attack, blood flow is blocked off in a coronary artery preventing blood from getting to the heart (Hopper & Williams. 2015, pg. 471).
Dementia is a nonreversible disease that occurs gradually and involves a deterioration of the patients’ cognitive function to a point where one loses ability to care for oneself, but it does not involve any abnormalities in level of consciousness. (Burton & Ludwig. 2015, pg. 751).
A palpitation is a rapid or irregular or strong heartbeat (Hopper & Williams. 2015, pg. 471).
Anemia lack of oxygen in the tissues caused by decreased oxygen in RBCs (Burton & Ludwig. 2015, pg. 543).
Angina, or chest pain (Hopper & Williams. 2015, pg. 465).
*Discuss the relationship between past/present diagnoses.
Pts primary diagnosis is hypertension, which is caused by a decrease in elasticity of the blood vessels, increased blood viscosity, and/or increased fluid volume. CKD (chronic kidney disease) is R/T hypertension by means of the hardening of the small blood vessels in the kidneys. Hyperlipidemia, lipids present in the blood that formulate thrombus within the blood vessels, is R/T CKD, which results in decreased metabolism of lipids, thus resulting in the pt’s heart palpitations due to accelerated atherosclerosis. Anemia is also R/T CKD due to impaired synthesis of erythropoietin, which is essential for bone marrow to rouse the formation of red blood cells; also due to the reduced life span of RBC’s from uremia and disturbance in action of folic acid (Hopper & Williams. 2015, pg 256). The dialysis treatment that the patient was placed on due to CKD is R/T nutritional deficiencies and blood loss which contributes to anemia (Hopper & Williams. 2015, pg 858). The obstruction of blood flow through the coronary arteries that is associated with CAD (coronary artery disease) is R/T the buildup of plaque made up of lipids along the arteries, or hyperlipidemia. This blood flow reduction also resulted in angina, or chest pains, and also the MI (myocardial infarction), or also known as a heart attack, that the pt had in 2004 (Hopper & Williams. 2015, pg 465). Dementia is most closely related to hyperlipidemia with blocks sufficient blood from reaching the brain via veins which results in damage to the brain (Hopper & Williams. 2015, pg 1154,1155). The hip pinning in 2005, as well as the amputation of two fingers from her left hand in 2005, are unrelated to each other and unrelated to the pts’ other health problems.
SIGNS AND SYMPTOMS...