•Name: Mr. Omar Hassan

•Age: 76

•Gender: Male

•Ethnicity: Middle Eastern

•Medical History: Chronic heart failure (CHF) – NYHA Class IV, hypertension, type 2 diabetes, chronic kidney disease (stage III)

•Recent Hospitalization: Admitted due to worsening dyspnea, fatigue, and fluid overload despite optimal medical management

Background

•Medical History: Chronic heart failure (EF 18%), hypertension, type 2 diabetes, CKD stage III

•Recent Labs:

·BNP: 1850 pg/mL (elevated, worsening heart failure)

·Creatinine: 2.1 mg/dL (signs of renal decline)

·Hemoglobin: 9.3 g/dL (anemia, likely chronic disease-related)

•Recent Medications:

·IV Furosemide (adjusted due to renal impairment)

·Morphine PRN for dyspnea

·Oxygen 2L via nasal cannula for comfort

Assessment:

•Neurological: Alert, but fatigued; anxious about his condition.

•Cardiovascular: BP 88/55, HR 108 (sinus tachycardia), cool extremities, +3 pitting edema.

•Respiratory: Dyspneic at rest, crackles in bilateral lung bases, SpO2 87% on room air, improved to 92% with 2L O2.

•Gastrointestinal: Poor appetite, small meals tolerated.

•Renal: Urine output reduced, signs of worsening renal function.

•Psychosocial: Family involved in care decisions; they are struggling with the idea of palliative care. The patient follows Islamic beliefs and has expressed the desire for comfort and dignity in his final days.

Recommendations:

•Continue comfort care measures: Oxygen, low-dose opioids for dyspnea.

•Monitor for worsening respiratory distress or pain.

•Encourage small meals for energy and hydration.

•Provide emotional and spiritual support to the patient and family.

•Follow up with the palliative care team to finalize goals of care discussions.

Recent hospitalization due to worsening symptoms despite IV diuretics.

Recent labs:

BNP: 1850 pg/mL (elevated)

Creatinine: 2.1 mg/dL (renal decline)

Hemoglobin: 9.3 g/dL (anemia)

Mr. Omar Hassan, a 76-year-old male, was recently hospitalized for worsening shortness of breath, fatigue, and fluid retention despite receiving optimal medical treatment.

Reduced urine output, poor appetite, fatigue, and increased anxiety.

Family struggling with palliative care decision-making, and the patient has expressed a desire for comfort and dignity in line with his Islamic beliefs.

• Neurological: Alert but fatigued; anxious about his condition.

• Cardiovascular: BP 88/55, HR 108 (sinus tachycardia), cool extremities, +3 pitting edema.

• Respiratory: Dyspneic at rest, crackles in bilateral lung bases, SpO2 87% on room air (improved to 92% with 2L O₂).

• Gastrointestinal: Poor appetite, tolerating small meals.

• Renal: Reduced urine output, worsening renal function.

• Psychosocial: Family involved in care decisions, struggling with palliative care discussions; patient desires comfort and dignity in his final days.

Provide emotional and spiritual support.

Engage palliative care team to finalize goals of care and facilitate family discussions.

• Recently admitted due to worsening symptoms, indicative of end-stage heart failure.

- Monitor for worsening respiratory distress or pain.

- Encourage small meals for energy and hydration.

- Provide emotional and spiritual support to Mr. Hassan and his family.

- Follow up with the palliative care team to finalize goals of care discussions, focusing on comfort and dignity in line with the patient’s wishes.

• Fatigue and weakness associated with disease progression.

• Nutritional challenges due to decreased appetite and possible fluid restrictions.

• Emotional and spiritual support needs due to the advanced nature of his illness.

Cardiovascular: cool extremities and +3 pitting edema. Sinus tach

Resp: Crackles in bilateral lung bases, 87% on RA, 92% with 2L on NC

GI: poor appetite

Renal: Reduction in urine output

Psychosocial: family involvement with the plan of care

Monitor for worsening respiratory distress or pain, adjusting medications as needed.

Encourage small, frequent meals to maintain energy and hydration.

Provide emotional and spiritual support for both the patient and family.

Collaborate with the palliative care team to discuss care goals and planning.

• He is down with low BP, tachycardia, and signs of poor perfusion.

• He is fatigued and anxious about his condition.

• Nutritional intake is limited due to poor appetite.

• He has reduced urine output and increased creatinine.

The lab for the patient indicated worsening HF and renal decline. The labs also showed signs of anemia that are most likely due to the patient's history of CKD. The patient is currently on IV furosemide, and it has been adjusted due to the patient's renal impairment. The HCP ordered morphine PRN for dyspnea and also has an order for O2 2L via nasal cannula

Resp: bilateral crackles in base of lungs, 92% SPO2 with 2L of O2

GI: poor appetite

Renal: reduced amount of urine ouput