401020 Professional Practice - Patient Diagnosis
Mr Jason Bilko is an 81 year old male (MRN: 12-34-56, DOB: 01/01/1937) who lives as 1 Soft Street, Chowtown, 4560. He presents to the emergency department on the 03/09/2018 at 1600hrs with chest pain and shortness of breath. He has had prior admissions to the hospital with Unstable Angina and has a history of multiple falls recently. On arrival, patient denies chest pain but has a resp rate of 32 and a SaO2 of 82% on room air. After you receive handover from the ambulance o?cers, you do an assessment on Mr. Bilko. You notice that his heart rate is 101bpm, SaO2 88%, BP 138/72, temp of 36.8 and Resp rate of 28. You document these in his observation chart and commence 6L O2 via a Hudson mask. You complete an ECG and attach the patient to a cardiac monitor-monitoring in sinus rhythm.
The ED sta? specialist, Dr Lance, reviews the patient and orders a chest x-ray. He reviews the ECG and notes no abnormalities. He inserts an IV cannula and takes blood. He orders IV ?uids which you commence. The patient returns from radiology and Dr Lance diagnosis the patient with mild pulmonary oedema and admits him under Dr Turner. He orders Furosemide 40mg IV which you administer. After you administer the medication, you repeat the observations and document them in the observation chart.
Answer
|
Title |
Family Name |
M.R.N |
12-34-56 | ||||
|
Bilko | |||||||
|
Given Names |
C.M.O | ||||||
|
Jason | |||||||
|
Address |
Street |
Age |
Sex |
DOB | |||
|
1 soft Street, Chowtown, 4560 |
81 years |
Male |
01/01/1937 | ||||
|
Suburb |
Postcode |
Adm. date | |||||
|
03/09/18 | |||||||
Patient details |
On 03/09/18 the patient was admitted to the hospital with issues related to shortness of breath, chest pain. It was also informed that the patient had a history of hospital admissions due to falls and unstable angina. | ||||||
Patient diagnosis |
After admission, patient denied the issue related to chest pain however his respiratory rate of 32 and a SaO2 of 82% was noted in the room air. After he entered the hospital and a detailed diagnosis was conducted, it was observed that his heart rate, BP and respiratory rate is 101 bpm, BP 138/72 and 88% respectively. Further, it was also observed from the ECG and X-ray that there is no abnormalities present. Further, IV cannula was inserted to collect blood samples, and it was observed that the patient has developed mild pulmonary oedema | ||||||
Medication |
The patient was provided with Furosemide 40 mg IV frequency of drug administration is 8 hours within 24 hours. And the medicine was administered twice at 08:00 and 16:00 AM. He was 0.9% sodium chloride solution and it started from 17:00 PM of that day. | ||||||
Patient observations |
The patient observations are as follows: Respiratory rate between 30-35 is not normal and should b taken into account as respiratory rate more than 25 implies severe health issue and heath is deteriorating. SaO2 at 85% is also not normal as the normal range is between 90 to 95%. O2 6L is normal for the patient Blood pressure 180/95 which is not normal as it is too high hence, blood pressure related interventions should be taken. Heart rate 125 bpm is elevated as for a normal human being 100 beats per minute is considered normal. As well it was also observed that neurological disability occurs while emergence of pain is not normal and if the pain persists it is important to check the pain score. | ||||||
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