Carl Shapiro is a 54-year-old male who travels frequently. He was seen in the Emergency Department at 1:30 p.m. for complaints of chest pain, diaphoresis, and shortness of breath. He was treated in the Emergency Department with aspirin and two doses of sublingual nitroglycerin. Chest pain improved with nitroglycerin administration. IV infusion of normal saline was started in the Emergency Department and is running at 25 mL/hour. Ordered lab values are pending. Provider wants to be called as soon as the labs are available. Patient is receiving oxygen at 4 L/min with SpO2 values at 97%. Chest pain was last rated as a “0” following second nitroglycerin dose and nitroglycerine patch 0.4 mg. He has been admitted to the Telemetry Unit.
Adm dx: acute myocardial infarction
DX: Angina, Acute Coronary Syndrome and Myocardial Infarction, Ventricular Fibrillation, Cardiac Arrest
Allergies: none
Height: 175cm
Weight: 110kg
Code status: Full
Subjective data
Patient smokes less than half park of cigarettes a day
Patient states BP is too high
Patient describes pain in chest
Patient had shortness of breath
| Assessment: |
| Psychosocial Assessment: can be creative
|
| Vital Signs:
HR- 80, RR-12, BP- 122/72, O2-98, T-99F, pain-0
|
| Neurological:
· No reports of pain · Alert and Oriented x4 · PERRLA · Pupils: 3mm |
| Musculoskeletal:
· Ambulates with walker · Muscle strength: 3+/5 · ROM within functional limits; lacks full range but able to complete daily routine · Sits up easily, able to raise legs onto bed, · Able to get out of bed with assistance of the walker |
| Cardiovascular:
· skin intact; warm to touch · S1 and S2 present · No edema present |
| Respiratory/Thorax:
o no cough present · skin intact; warm to touch; no moisture · no oxygen delivery device |
| G-I/Abdominal:
· eats majority of food o breakfast consisted of eggs, bacon, toast, and orange juice · bowel sounds present in all quadrants; normoactive · skin intact, warm, no moisture, stretch marks present across abdomen · last bowel movement unknown |
| G-U:
· Urine appears pale yellow (in Depend) o No odor, no blood, no reports of pain |
| Integument:
· Skin intact o warm to touch o no excessive moisture o no evidence of pressure ulcers or breaks · hair texture is smooth o thinning o grey color o evenly distributed · finger nails intact, trimmed properly, normal color, normal thickness · toenails intact; yellowish color |
| Knowledge:
Aware in regards to past and current medical conditions |
Lab data
| Diagnostic Measure | Patient Value | Normal Range |
| HCO3- | 18 | (22-26 mEq/L) |
| NA+ | 140 | (133-143 mEq/L) |
| Hb | 14 | (13.5-17.5 g/dL) |
| HCT | 44 | (40-45%) |
| WBC | 8.2 | 4-11*10-9/L |
| Platelets | 295 | (150-400*10-9/L) |
| Creatinine | 0.7 | (0.8-1.4mg/dL) |
| CK-MB | 20 | (0-4.9 ng/mL) |
| Troponin T | 2.2 | (0-0.1 ng/mL) |
Medications
| Generic Name (Trade Name) | Dose/Route/Frequency |
| Aspirin | 320 mg
PO Once daily as initial dose |
| Nitroglycerin | 0.4 mg
Transdermally Once daily for 12 to 14hours (0800) |
| Nitroglycerin | 0.6mg sublingually every 5 minutes as needed, up to 3 doses |
| Morphine
|
2mg
Iv push for chest pain every 10 mins as needed, up to 3 doses |
| Normal saline | 25ml/hr
Iv |
ANSWER:
Pt initials C.S.
Patient Information
Carl Shapiro is a 54-year-old male who travels frequently. He was seen in the Emergency Department at 1:30 p.m. for complaints of chest pain, diaphoresis, and shortness of breath. He was treated in the Emergency Department with aspirin and two doses of sublingual nitroglycerin. Chest pain improved with nitroglycerin administration. IV infusion of normal saline was started in the Emergency Department and is running at 25 mL/hour. Ordered lab values are pending. The provider wants to be called as soon as the labs are available. The patient is receiving oxygen at 4 L/min with SpO2 values at 97%. Chest pain was last rated as a “0” following second nitroglycerin dose and nitroglycerine patch 0.4 mg. He has been admitted to the Telemetry Unit. To continue reading, click the button below.