Case Study: Acute Coronary Syndrome Diagnosis & Management in 60-Year-Old Male, Exams of Nursing

Download Case Study: Acute Coronary Syndrome Diagnosis & Management in 60-Year-Old Male and more Exams Nursing in PDF only on Docsity! NR 603 WEEK 3 CASE STUDY NR 603 Week 3-2 Subjective: L.M. 60 year old, African American, Male Major events: Tonsillectomy, Adenoidectomy, Cholecystectomy, and Vasectomy. Ongoing medical problems: Hypertension, Hypercholesterolemia. Family health history: Father: Lung cancer, Mother: (Deceased)-complications from a CVA. Brother: (Deceased at 44)-malignant melanoma. Preventive care: Not up to date on annual influenza vaccine. Social history: Lives with his wife of twenty years and works as an architect. Social cigar smoker and social alcohol use “when playing poker with friends.” Allergies: NKDA. Chief Complaint: “Chest pain three days ago.” HPI: 60 year old, male, presents to the office “because my wife made me come” due to having “heaviness in my chest” upon exertion, onset three day ago with nausea, shortness of breath, diaphoresis, and lasting approximately three minutes. Also reports feeling more fatigued than usual. REVIEW OF SYSTEMS: General: No weight change, generally healthy, no change in strength. Head: No headaches, no vertigo, no injury. Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain. Ears: No change in hearing, no tinnitus, no bleeding, no vertigo. Nose: No epistaxis, no coryza, no obstruction, no discharge. Mouth: No dental difficulties, no gingival bleeding. Neck: No stiffness, no pain, no tenderness, no noted masses. Chest: No wheezing, no hemoptysis. Heart: No palpitations, no syncope, no orthopnea. Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no emesis, no melena. GU: No urinary urgency, dysuria, hematuria. Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias or numbness. Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia. Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content. Denies fever, chills, vomiting, foreign travel. Not exposed to similar sick contacts. Objective: Vital Signs: BP 140/90, O2 97%, Unknown temperature, heart rate, or respirations. BMI: 33.5 General Physical Exam: Hypertensive, in no acute distress. Head: Normocephalic, no lesions. Eyes: PERRLA, EOM's full, conjunctivae clear. Ears: EAC's clear, TM's normal, light reflex noted, no tenderness to pinna or tragus. Nose: Deviated septum, right side, mucosa normal, no obstruction. Throat: Teeth in poor repair, gums reddened and receding, filled cavities noted. Tongue smooth, pink, no lesions, protrudes in midline, clear, no exudates. Neck: Mild JVD in recumbent position, supple, no masses, no thyromegaly, no bruits. Chest: Lungs clear, no rales, no rhonchi, no wheezes. Heart: Heart S1 and S2 noted, RR, no murmurs, noted. No parasternal lifts, heaves, and thrills. Peripheral pulses equally bilaterally. PMI 5th ICS displaced 4cm laterally. No edema in lower extremities. Abdomen: Soft, no tenderness, no masses, BS normal. Back: Normal curvature, no tenderness. Extremities: FROM, no deformities, no edema, no NR 603 WEEK 3 CASE STUDY erythema. Neuro: Physiological, no localizing findings. Skin: Normal, no rashes, no lesions noted. Assessment: Diagnoses: 1. Acute Coronary Syndrome (I24.9) 2. Acute Angina (I20.0) 3. Hypertension (R03.0) 4. Hypercholesterolemia (E78.00) 5. Non-Compliance with medical regimen and treatment (Z91.19) 6. Obesity (E66.9) Plan: If symptoms are no better, or there are worsening of symptoms instructed to seek medical attention, or go to emergency room. Referred to cardiology and arrange follow up with cardiologist prior to leaving office for presenting symptoms, and give a referral for a nutritionist on tips to help with healthy, eating habits, and weight loss. Specialized cardiology services have contributed to reducing mortality in acute coronary syndrome (O’Neill, et al., 2017). Patients who suffer from cardiovascular disease must modify their diet. Managing one’s diet will help to decrease their mortality rate, however in knowing this the patient must be compliant (Juma, Imrhan, Vijayagopal, & Prasad, 2015). It is also important they are given the appropriate resources in order to be complaint with the diet given. Larry maintaining a cardiac diet will not only lower his cholesterol and hypertension, but it will help to reduce his mortality rate. Along with this, Larry should limit his alcohol intake to two drinks daily. The antithrombotic effects of alcohol probably increase the risk of hemorrhagic stroke whilst lowering ischemic stroke risk (Klatsky, 2015). In knowing this, along with Larry’s family history, it is important to educate him on his alcohol intake along with smoking cessation. Medications such as Wellbutrin could be offered, or smoking aids such as Nicorette. Smoking remains the leading cause of preventable morbidity and mortality (Prochaska & Benowitz, 2015). Exercise should be implemented once cleared by cardiology, however should not be implemented until clearance due to having chest pain upon exertion. Review the benefits of the medications prescribed along with their side effects, and discuss the importance of being compliant. Discuss the importance of monitoring daily weights along with keeping a diary of blood pressure readings. Failure to comply with educational materials can cause the patient’s disease process to worsen. Medications attached to this encounter: • Aspirin 81mg, take one tablet by mouth once daily • Caduet 2.5mg/20mg, take one tablet by mouth once daily • HCTZ 25mg, take one tablet by mouth once daily