NURS 5461/N5462  Adult-Gerontology Management Across the Lifespan

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Differential Diagnoses Assignment Answer Sheet

NURS 5461/N5462  Adult-Gerontology Management Across the Lifespan

Topic:______________________________          Date:___________________________

Name:______________________________

Assessment

_______40% Medical Diagnoses with ICD-10 Codes:

1. Palpitations (R00.2: Chief complaint; the patient experienced a sudden onset of rapid, pounding heartbeat while at rest). Needs further evaluation (Gadó et al., 2022).
2. Tachycardia, unspecified (R00.0): HR of 130 bpm noted on exam with irregular rhythm; requires monitoring and diagnostic workup (Gadó et al., 2022).
3. Atrial fibrillation, unspecified (I48.91): Irregular rhythm, rapid rate, murmur, and history of irregular heartbeats raise high suspicion for AFib (Gadó et al., 2022).
4. Congestive heart failure, unspecified (I50.9): Bilateral basal crackles and pretibial edema suggest early fluid overload. Needs confirmation.
5. Essential hypertension (I10): Known history of HTN, currently treated with Lisinopril; BP today 130/74 (Gadó et al., 2022).
6. Coronary artery disease (I25.10): History of CAD with current cardiac symptoms; CAD is a significant risk factor for arrhythmias and CHF (Gadó et al., 2022).
7. Systolic heart murmur, unspecified (R01.1): New systolic murmur heard on exam; potentially valvular and must be evaluated further (Gadó et al., 2022).
8. Anemia, unspecified (D64.9): Hgb of 11 g/dL and Hct of 33% indicate mild anemia, which could contribute to fatigue and cardiac strain (Gadó et al., 2022).
9. History of renal cell carcinoma (Z85.528): It is essential to monitor post-nephrectomy status and possible metastatic disease that may impact treatment decisions (Gadó et al., 2022).
10. Overweight, adult (E66.3): BMI 31.5 places her in the overweight category; modifiable risk factor for cardiovascular disease (Gadó et al., 2022).

Differential Diagnoses with ICD-10 codes [List the most likely differentials for the chief complaint; limit your differentials [diagnoses that you are trying to rule in or rule out] to 6; and be sure and include ICD-10 codes for each differential]

• Rule out #1: Atrial Fibrillation (I48.91): Irregularly irregular rhythm and rapid rate strongly suggest AFib; history of irregular heartbeat supports this.
• Rule out #2: Paroxysmal Supraventricular Tachycardia (PSVT) (I47.1): Sudden onset of palpitations and lightheadedness could be due to PSVT, especially with abrupt resolution.
• Rule out #3: Anemia-related tachycardia (D64.9): Hgb 11 g/dL and fatigue suggest anemia may contribute to elevated heart rate and palpitations.
• Rule out #4: Hyperthyroidism (E05.90): Palpitations and weight stability don’t rule it out; thyroid dysfunction can cause new arrhythmias.
• Rule out #5: Congestive Heart Failure (I50.9): Edema, basal crackles, exertional SOB, and CAD history raise concern for CHF.
• Rule out #6: Anxiety disorder, unspecified (F41.9): While less likely, it must be considered in the setting of new-onset palpitations with no ischemic signs or severe symptoms.

Nursing Diagnosis/Health Maintenance or Social Issue: [List one nursing, health maintenance, or social issue here with an ICD-10 code; looking for a diagnosis, not an intervention—education/intervention should be listed below, not here in the diagnosis section]:

• Knowledge deficit related to cardiac symptoms and self-care management (Z55.9: Problems related to education and literacy, unspecified): The patient has a history of irregular heartbeat, CAD, and nephrectomy but has limited understanding of current cardiac symptoms and has not maintained routine aspirin therapy. Education on cardiac health, symptom monitoring, and medication adherence is necessary.

Initial Treatment Plan

________20% Diagnostics/Laboratories [List any additional diagnostics or lab tests you believe are needed]

• 12-Lead ECG (CPT 93000): To evaluate for arrhythmia, specifically atrial fibrillation or other supraventricular tachycardias, given her irregular and rapid pulse (Gadó et al., 2022).
• Holter Monitor (CPT 93224): 24- to 48-hour ambulatory ECG monitoring to detect intermittent arrhythmias and correlate with symptoms of palpitations and light-headedness (Gadó et al., 2022).
• Echocardiogram (CPT 93306): To assess cardiac structure and function, especially to evaluate for valvular disease and left atrial enlargement (given the murmur and irregular rhythm) (Gadó et al., 2022).
• TSH with reflex free T4 (CPT 84443, 84439): To rule out hyperthyroidism as a reversible cause of palpitations and tachyarrhythmias (Savelieva et al., 2023).
• BNP or NT-proBNP (CPT 83880): To assess for underlying heart failure, given the presence of pretibial edema and crackles at lung bases (Savelieva et al., 2023).
• Magnesium and Electrolyte Panel: To identify possible electrolyte imbalances (such as hypomagnesemia and hypokalemia) that may contribute to arrhythmias (Savelieva et al., 2023).

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________20% Rxs [Identify initial prescriptions, referrals, nonpharmacological medical treatments needed; there may be situations when you do not need to order something.]

• Referral to Cardiology: For further evaluation of arrhythmia, possible atrial fibrillation, and murmur assessment; may require additional testing like stress testing or advanced rhythm monitoring (Savelieva et al., 2023).
• Resume Aspirin 81 mg PO daily: Low-dose aspirin may be restarted if not contraindicated post-nephrectomy, especially given her CAD history. Confirm with oncology or surgery if needed (Savelieva et al., 2023).
• Consider anticoagulation: If atrial fibrillation is confirmed, assess stroke risk (CHA₂DS₂-VASc score) and consider initiating anticoagulation (such as apixaban) unless contraindicated (Savelieva et al., 2023).
• Continue Metoprolol Succinate 50 mg PO QHS: This beta-blocker helps control heart rate and may reduce palpitations. Consider dose adjustment if arrhythmia persists.
• Lifestyle Modifications: Encourage salt restriction (<2 g/day), fluid monitoring, and regular light physical activity as tolerated to support cardiovascular health.
• Home Blood Pressure and Pulse Monitoring: To track rate control and detect recurrence of tachyarrhythmia symptoms.

________20% Nursing Interventions/Education [cite follow-up and specific health promotion and education needs]

• Symptom Monitoring and Education: Instruct the patient to keep a daily log of palpitations, dizziness, shortness of breath, and any new or worsening symptoms. Educate her to seek immediate care if she experiences chest pain, syncope, or worsening dyspnea (Ciumărnean et al., 2021).
• Medication Adherence: Reinforce the importance of taking metoprolol and lisinopril as prescribed. Educate on the purpose of each medication and potential side effects (such as fatigue and bradycardia) (Ciumărnean et al., 2021).
• Heart Rate and Blood Pressure Monitoring: Teach the patient how to monitor pulse and BP at home. Review target parameters and when to report abnormal findings (Ciumărnean et al., 2021).
• Lifestyle Counseling: Guide on reducing cardiovascular risk: emphasize a heart-healthy diet (such as DASH), smoking avoidance, maintaining a healthy weight, and engaging in light physical activity as tolerated (Ciumărnean et al., 2021).
• Follow-up: Schedule a follow-up visit in 1 week to review diagnostic results (such as ECG, labs), reassess symptoms, and discuss potential medication adjustments or further referrals (Ciumărnean et al., 2021).
• Health Promotion: Discuss the importance of managing chronic conditions (HTN, CAD) and maintaining regular follow-up with her oncologist due to recent renal cell carcinoma treatment (Ciumărnean et al., 2021).

_______ TOTAL (100%)

References

Ciumărnean, L., Milaciu, M. V., Negrean, V., Orășan, O. H., Vesa, S. C., Sălăgean, O., Iluţ, S., & Vlaicu, S. I. (2021). Cardiovascular risk factors and physical activity for the prevention of cardiovascular diseases in the elderly. International Journal of Environmental Research and Public Health, 19(1), 207. https://doi.org/10.3390/ijerph19010207

Gadó, K., Szabo, A., Markovics, D., & Virág, A. (2022). Most common cardiovascular diseases of the elderly—a review article. Developments in Health Sciences, 4(2), 27–32. https://doi.org/10.1556/2066.2021.00048

Savelieva, I., Fumagalli, S., Kenny, R. A., Anker, S., Benetos, A., Boriani, G., Bunch, J., Dagres, N., Dubner, S., Fauchier, L., Ferrucci, L., Israel, C., Kamel, H., Lane, D. A., Lip, G. Y. H., Marchionni, N., Obel, I., Okumura, K., Olshansky, B., . . . Grodzicki, T. (2023). EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). EP Europace, 25(4), 1249–1276. https://doi.org/10.1093/europace/euac123\

Takase, B., Ikeda, T., Shimizu, W., Abe, H., Aiba, T., Chinushi, M., Koba, S., Kusano, K., Niwano, S., Takahashi, N., Takatsuki, S., Tanno, K., Watanabe, E., Yoshioka, K., Amino, M., Fujino, T., Iwasaki, Y., Kohno, R., Kinoshita, T., . . . Sumitomo, N. (2023). JCS/JHRS 2022 Guideline on Diagnosis and Risk Assessment of Arrhythmia. Circulation Journal, 88(9), 1509–1595. https://doi.org/10.1253/circj.cj-22-0827