Name: Charles Jones This scenario involves a 68 year old male with acute exacerbation of congestive heart failure (CHF).

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Name: Charles Jones
This scenario involves a 68 year old male with acute
exacerbation of congestive heart failure (CHF). The patient had
been admitted to the telemetry unit yesterday from the emergency
department due to respiratory distress, extreme fatigue, weight
gain, and bilateral ankle edema.
Gender: M Age: 68 Race:
African-American
Weight: 95
kg
Height: 183 cm
Religion: Baptist Major Support:
Spouse
Allergies: None known
Immunizations: up to date with annual flu
vaccine
Past Medical History: Benign Prostatic
Hypertrophy, Hypertension, Atrial fib, Congestive heart failure,
hyperlipidemia, 1 pack a day smoker (quit 2 years ago), social
drinker.
History of Present illness: Presented to
emergency department yesterday with dyspnea, fatigue, weight gain
of 10 lbs, and ankle edema. Diagnosed with exacerbation of CHF.
Treated with diuretics, angiotensin-converting enzyme inhibitors,
beta blockers and a second dose of diuretics after which he
improves.
Social History: Lives with spouse, both now
retired. Worked as a school maintenance supervisor. Three
adult children, very supportive to their parents.
Primary Medical Diagnosis:
Exacerbation of chronic heart failure
Surgeries/Procedures & Dates:
echocardiogram performed in ED