Comments: Carl Shapiro is a 54-year-old male who travels frequently.
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Get it written →Comments: Carl Shapiro is a 54-year-old male who travels frequently. He was seen in the Emergency Department a couple of hours ago 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. Normal saline is infusing at 25 mL/hour. A chest x-ray was done. Basic metabolic panel, complete blood count, troponin, and CK-MB lab values are pending. The provider wants to be called as soon as the labs are available. Patient is receiving oxygen at 4 L/min with Sp02 values at 97%.
| Chief Complaint | Dull aching chest pain and shortness of breath |
|---|---|
| Primary Concern – Admission Diagnosis | Angina — coronary artery disease |
Other Problems/Diagnosis:
|
Signs and Symptoms: Has a history of hypertension. He states he takes “water pills” for his blood pressure (he is not sure of the name of the pill) and has been trying to exercise and lose weight but admits it is very hard when he travels. He smokes less than half a pack of cigarettes a day and drinks alcohol occasionally. He describes his work as “stressful.”
Recent admit from Emergency Department with chest pain, diaphoresis, and shortness of breath.
Interventions:Code team were called with code cart,CPR compression performed and epinephrine was administer every3-5 minute. Patient was reassess after each CPR.
Care a plan of care and SBAR for this patient.
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