Assessment based on his current physiologic condition

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Reference no: EM133854280

Assignment:

A 63-year-old Asian American male, is brought to the emergency department by ambulance at 6 AM with complaints of chest tightness, shortness of breath (SOB), and palpitations. The paramedics have started an IV and O2 at 2 L/min via nasal cannula. They also administered four chewable baby ASA and a nitroglycerin tablet, and they obtained a 12-lead ECG. L.P. is pain free on arrival but still complains of palpitations.

Subjective Data:

PMH:History of hypertension, mitral valve prolapses with mild regurgitation, heart failure, and type 2 diabetes.

Medications:Lisinopril (Prinivil) 10 mg/day PO, metoprolol (Lopressor) 50 mg PO BID, ASA 81 mg/day PO, furosemide (Lasix) 40 mg/day PO, and glipizide (Glucotrol) 5 mg/day PO.

Health Perception-Health Management:P. denies any previous history of chest pain or CAD. He was feeling fine until this morning when he awoke and experienced SOB, chest tightness, and palpitations while walking to the bathroom. He became frightened that he was having a heart attack, so his wife called 911. Denies smoking or alcohol intake. SOB and chest tightness are now gone, but he continues to feel palpitations.

Elimination: Denies any edema. States takes Lasix in the morning and typically "passes urine until lunchtime." Denies nocturia.

Objective Data

BP 100/54, apical-radial pulse 154, pulse irregular, respiratory rate 20, temperature 98.2° F (36.8° C), O2saturation 94% on room air
Awake, alert, and oriented ×3
Lungs clear on auscultation; systolic murmur present
Heart monitor shows atrial fibrillation with a rapid ventricular response
+1 pedal pulses bilaterally
No peripheral edema, jugular venous distention, or heaves noted

Discussion Questions

How will you individualize the assessment based on his current physiologic condition? What other information would you ask him about his condition? What should be included in the physical assessment?
Based upon the information from the subjective and objective findings which is most concerning to you and why?
Based upon the patient medications and objective data what laboratory and diagnostic tests would you anticipate and why?

Reference no: EM133854280

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