PGCC Nursing Critical Care of Acute Coronary Syndrome Presentation Patient information 54 YO African American female Christian Disabled lives alone in a

PGCC Nursing Critical Care of Acute Coronary Syndrome Presentation Patient information 54 YO African American female Christian Disabled lives alone in apartment Presented to ER C/O chest pain for the past day. HPI: Ran out of diuretic, chest pain on exertion Diagnosis: Depression, Old GSW, PMH: Heart Failure, HTN, Hyperlipidemia, DM type 2, PSH: Rt side Nephrectomy, SOC: smoke 1 ½ PPD, 5th of vodka daily, past cocaine Allery: NKDA Home meds: Lisinopril, “fluid pill”, Baby ASA Gen: T 98.2 F Neuro: PERRLA, Alert, oriented person, place, time. Clear speech, hands tremulous CVS: BP 138/105 HR 61 regular. S1 S2, no murmur. Cardiac monitor Normal sinus rhythm, no edema present, cap refill <2 seconds, all extremities pulses 2+, Saline lock rt hand. Resp: RR 18/min, unlabored, breath sounds clear bilaterally, no use accessory muscles, Oxygen 2L/min, Pulse ox 98%, Abd: bowel sounds normoactive, soft, non-tender, distended GU: Voiding freely with urinal Mus/skel: Weak, able to stand requires cane, 1 person assist Integ: Color even, no rash or wounds noted Home Meds: ASA, Plavix, Lopressor, Admitting Dx: Acute Coronary Syndrome. Hospital Meds: ASA, Plavix, Lopressor, Lisinopril, NTG SL PRN, Tylenol Diagnostic: CXR: no acute disease, cardiomegaly EKG: NSR, no acute changes Lab Results: WBC: WBC 5.3, Hgb 13.4, Hct 39.6, Plat 221 Chemistry: Na 135, K 4.0, Cl 102, CO2 27, Glucose 108, BUN 15, Creatinine 1.02, troponin <0.15, BNP 22 Patient information 54 YO African American female Christian Disabled lives alone in apartment Presented to ER C/O chest pain for the past day. HPI: Ran out of diuretic, chest pain on exertion Diagnosis: Depression, Old GSW, PMH: Heart Failure, HTN, Hyperlipidemia, DM type 2, PSH: Rt side Nephrectomy, SOC: smoke 1 ½ PPD, 5th of vodka daily, past cocaine Allery: NKDA Home meds: Lisinopril, “fluid pill”, Baby ASA Gen: T 98.2 F Neuro: PERRLA, Alert, oriented person, place, time. Clear speech, hands tremulous CVS: BP 138/105 HR 61 regular. S1 S2, no murmur. Cardiac monitor Normal sinus rhythm, no edema present, cap refill Purchase answer to see full attachment