Mr Borg Case Study

Mr. Borg stands 5 foot 11 inches tall and weighs 210 pounds. Vital signs: oral temperature of 99.0 degrees Fahrenheit, blood pressure110/68 via left arm, heart rate102 bpm, respirations of 20, and oxygen saturation 96% on room air. Patient is awake, alert, and oriented to person, place, and time. Head is normocephalic, without masses, lesions, and/or abnormalities. Eyes are equally round and reactive to light, with extra ocular movements intact; no pallor or icterus noted; reading glasses are used when needed. Throat is red with swollen glands, tenderness noted when patient swallows. Nasal congestion noted. No thrush noted in the mouth. Ears are clear of drainage; no redness noted. No lymphadenopathy or thyromegaly noted in the neck. Rhonchi

Heart rate with normal sinus rhythm; heard sounds S1 and S2, without murmur, rubs, or gallops. Abdomen is non-distended and non-tender; bowel sounds are present in all four quadrants; negative for pain or guarding; no masses noted. Foley catheter in place draining clear yellow urine. Last bowel movement noted yesterday evening, without complications; normal tone, hard stool noted; guaiac negative. Skin is pink in color; warm to touch and has adequate texture and turgor. Equal weakness noted bilaterally; hands and feet are cool to touch; no clubbing noted. Patient has +1 pitting edema that extends to the mid-calf. Geriatric Depression scale score > 10, indicating mild depression Patient’s current medications include metformin (Glucophage), insulin human regular (HumuLIN R), warfarin (Coumadin), furosemide (Lasix), carvedilol (Coreg), captopril (Capoten), potassium (KDur), thiamine (Thiamilate), multi-vitamin (One-A-Day), trazadone (Desyrel), moxifloxicin (Avelox), amiodarone (Cardarone), and a nitroglycerin patch (Nitro-Dur). ECG revealed that the distal two thirds of the left ventricle was akinetic. Cardiac Catheterization revealed 80% occlusion of the left coronary artery and severe diffuse disease of the left anterior descending