NR 576 Week 7 iHuman Virtual Patient Encounter Attempt 3846058 - Diego Perez

History Notecard by Nada Issa on case Diego Perez Use this worksheet to organize your thoughts before developing a differential diagnosis list. 1. Indicate key symptoms (Sx) you have identified from the history. Start with the patient's reason(s) for the encounter and add additional symptoms obtained from further questioning. 2. Characterize the attributes of each symptom using "OLDCARTS". Capture the details in the appropriate column and row. 3. Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider the patient's age and risk factors.) Use your ideas to help guide your physical examination in the next section of the case. HPI Sx = Sx = Sx = Sx = Sx = Sx = Onset Location Duration Characteristics Aggravating Relieving Timing / Treatments Severity Attempt: 3846058 Report generated on 3/16/2026, 8:12:31 PM America/Denver Management Plan by Nada Issa on case Diego Perez Diagnostics: Chest Xray, 12 lead ECG, CBC, CMP, BNP, lipid profile Medications: Please follow admitting team medication recommendations : you will most probably be started on Valsartan 49/51 mg PO BID, Metoprolol 25 mg PO daily after IV furosemide, Spironolactone 25mg PO daily Referrals: Refer patient to ED for hospital admission Outpatient cardiology follow up upon hospital discharge Education: 1. Reason for Hospital Admission You are experiencing worsening symptoms of heart failure, including shortness of breath, orthopnea, recent weight gain, and leg swelling. Your chest X-ray demonstrates pulmonary congestion and cardiomegaly, and your BNP level is elevated at 630, indicating increased cardiac strain. Because you require intravenous (IV) diuretics and close monitoring of your heart and kidney function, outpatient management would not be safe at this time. Hospitalization is recommended for patients with significant congestion and the need for IV diuresis (Heidenreich et al., 2022; McDonagh et al., 2021). 2. What Will Happen in the Hospital During your hospital stay, you will receive IV diuretics, mainly a medication called Lasix, to remove excess fluid and reduce strain on your heart. You will be placed on cardiac monitoring (telemetry), undergo an echocardiogram to evaluate heart function, and have laboratory monitoring of kidney function and electrolytes. Your blood pressure medications will be restarted and optimized as part of guideline-directed medical therapy, which has been shown to reduce mortality and rehospitalization (Heidenreich et al., 2022). 3. Medication Adherence It is essential that you do not stop blood pressure or heart medications without consulting your healthcare provider. Medication non-adherence is a common cause of heart failure exacerbations and hospital admissions. Consistent use of prescribed medications significantly improves survival and decreases the risk of rehospitalization (Heidenreich et al., 2022). 4. Daily Weight Monitoring You should weigh yourself every morning after urinating and before eating, using the same scale and wearing similar clothing. You should notify your provider if you gain 2–3 pounds in 24 hours or 5 pounds in one week, as this may indicate fluid retention. Early detection of weight changes allows for timely intervention and reduces preventable readmissions (Riegel et al., 2017). 5. Sodium Restriction You