Concept Map Patient Profile KJ is a 55 year old male admitted to the hospital with chef complain of Chest Pain and Syncope. Patient stated that he was watching TV when he started to have Chest pain with nausea and vomiting. This pain was the same as when he had his MI 3 years ago. He called 911 and the ambulance has transported him to Holy Cross. In the ER the patient has stated that few days before admission he has lost consciousness and fell to the ground, however do damage was caused by the fall. After admission the patient had the fallowing testing performed Lexiscan Stress Test: No EKG evidence for Ischemia Chest X-Ray: Heart & lung clear, no evidence of consolidation, pleural effusion, pneumothorax Cervical Spain CT: bones are normal, soft tissue normal , no abnormalities detected on any structures …show more content…
He said that the pain was going from his feet up to his hips. He received Norco and reported good pain relief. The patient HTN medication Carvediolo and Lasix were administer which lower his B/P from 131/85 to 110/83. The patient has received his aspirin. He also received his antianxiety medication, antipsychotic medication for his anxiety after which the patient fall asleep. The patient was on sliding scale insulin and received Insulin @ 0900 of 2 units after his glucose levels were 140. At 1300 however, the patient has refused to take his Inulin even though his sugar levels were 155. He stated that he is upset and did not want to take the medication. Vitals signs on this day were: T:37 P:83 R:20 BP 110/83. The patient was oriented x3. The patient was irritated and not complained, body movement were voluntary, his skin was warm and capillary refill < 3 seconds which indicated good circulation. The patient lungs were clear posteriorly and anteriorly in upper and lower part of the lungs. His O2 sat. was 98% . Patient bowel sounds were present and last BM was 1 day