Adm dx: acute myocardial infarction

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.

 

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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

 

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