Name: Sylvester Pacino Age: 57 years Sex: Male Admission history: Paramedics called and found patient in tripod position breathing
Name: Sylvester Pacino Age: 57 years Sex: Male Admission history: Paramedics called and found patient in tripod position breathing at 32 breaths per minute, HR 144 irregular. Cyanotic lips, generalized weakness, only nodding yes/no to questions asked, Sp02 84% on R/A. Unable to obtain clear ECG. Oxygen 2L nasal canula applied as patient rushed lights and sirens to hospital, arrival time to ED 2142. Patient reported increasingly worsening shortness of breath (SOB) at rest with heaviness in chest and associated dizziness starting at 1440 today after working in garage. Normally his SOB is only with exertion. 1. The nurse documents these initial assessment findings: Subjective: • States that he feels “heaviness” in his chest because he “can’t get enough air in” o Rates chest ‘pressure’ 8/10 diffuse across chest with some noted in upper back, worse with inspiration. • Reports unable to lie flat requiring multiple pillows in bed or sometimes has to sleep in chair over the last week. • Swelling in both his lower legs “for some time” and pants not fitting the same • Past Medical History: Obstructive sleep apnea (OSA), remote DVT, Ex-smoker, coronary artery disease (CAD) with stent via PCI x 2, 1.5 years ago, Dyslipidemia, Borderline HTN, recent stress of losing his sister from an MI (age 67)
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