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Chief Informant: Patient (Akana, Keola)
Chief Complaint: “Heart failure complications”
H O S P I T A L
History of Current Problem: Patient reports a history of shortness of breath with exercise for the past several months.
One week ago he experienced worsening shortness of breath including mild dyspnea at rest. Primary provider added
digoxin to medication regimen 3 days ago. Patient reported continued worsening dyspnea and provider ordered direct
admission for medication adjustment, monitoring, and cardiac rehabilitation.
Allergies: None
Previous Illnesses: No significant history
Injuries or Trauma: No significant history
Surgical History: None
Dietary History: Cooks for self and wife. Prefers traditional Hawaiian foods
Social History: Second marriage. Lives with wife. Has 3 adult children.
Current Medications: Furosemide 40 mg by mouth daily, digoxin 0.25 mg by mouth daily, atenolol 50 mg by mouth daily,
potassium chloride 10 mEq by mouth daily.
Review of Systems
Integument: No reported concerns.
HEENT: Mild headache this morning which the patient attributes to the transfer vehicle ride. No history of headaches. No
recent changes in vision or hearing.
Cardiovascular: No history of hypertension. Denies chest pain. Swelling in ankles and feet.
Respiratory: No recent respiratory infections. Complains of recent increased difficulty breathing even at rest.
Gastrointestinal: Denies issues. Bowel movements regular.
Genitourinary: Denies frequency, urgency, or recent changes in urination.
Musculoskeletal: Denies pain in joints or back. Reports weakness related to shortness of breath.
Neurologic: Denies movement and sensation issues. Denies problems with cognition or memory.
Endocrine: No reported concerns.
1) MAke SBAR
Laboratory Results
Basic Metabolic Panel
Blood Urea Nitrogen
40 mg/dL
Chloride
103 mEq/L
Carbon Dioxide
30 mEq/L
Creatinine
2.3 mg/dL
Glucose
149 mg/dL
Potassium
5.8 mEq/L
Sodium
134 mEq/L
Calcium
8.8 mg/dL
Digoxin Level
Digoxin level
2.3 ng/mL
SCIENCE
HEALTH SCIENCE
NURSING
