Patient Name John Doe, 65 years old. Admission Date March 15, 2023. Diagnosis of Acute Myocardial Infarction.
History:
- Doe’s past includes hypertension, hyperlipidemia and type 2 diabetes.
- His coronary bypass surgery (CABG), was performed five years ago.
- A retired worker in construction, he lives alone in his single-story home.
Assessment:
- Doe can be alerted and directed to the person, place and time.
- The chest pain radiates from his left arm and started about 4 hours ago.
- These vital signs include blood pressure of 140/90mmHg, heart beat 90 bpm and respiratory rate 22. BPM, as well as oxygen saturation at 90% in the room.
- The cardiovascular examination revealed a consistent rhythm that included a loud, sonic S4 sound at the top and a 3-/6 holosystolic murmur at the bottom.
- A respiratory assessment shows crackles in the base of the lungs.
- Neurological assessment reveals no deficits.
Plan:
- Aspirin, Nitroglycerin, Heparin were used to start Mr. Doe.
- To continue his management and monitoring, he was transferred to the heart unit.
- AMI was confirmed by the ordering of cardiac enzymes.
- An echocardiogram was done to determine if there were any changes or worsening problems with the heart.
- His diabetes was managed by blood glucose monitoring.
Interventions:
- In order to keep Mr. Doe oxygen-saturated above 92%, Mr. Doe was put on oxygen therapy.
- Intravenous morphine was used to manage pain.
- To reduce myocardial demands, bed rest was recommended.
- His hypertension, hyperlipidemia and hypertension were managed by a low-fat diet with low sodium.
- M. Doe was educated about his condition and treatment.
Summary:
- A 65-year old male with severe chest pain was admitted to the hospital by Mr. Doe. He also has a history AMI.
- His AMI is currently being managed with medication and surveillance.
- To confirm and diagnose any cardiac problems, echocardiography was ordered.
- These include pain management, oxygen therapy, medication management and diet management.