1. My stomach is burning. Can you give me some Maalox or something?
Mrs. Merritt is a 69 y/o female who has just been transferred to your floor from the ED for treatment of ACS. She has CAD, DM, PVD by history, MI X 1. She is highly allergic to Contrast and Benadryl and is awaiting evaluation for the catheterization lab . She received, Plavix, nitroglycerin and metoprolol in the ED. She has a routine ACS order set and is awaiting evaluation by her HCP.
MR#
122334
Gender Identity  F
Hgt
 5’9’’
Last Name
 Mannix
Marital Status  W
Wgt
 88 kg
First Name
 Jane
DOB
 9/X/20XX
age 
 71
HCP
 Jones
Admitting Date
 X/XX/XXXX
Preferred Language
 English
Spirituality
Presbyterian
Reason for visit
 epigastric discomfort, orthopnea, pedal edema, sleeping with two pillows
HPI
 Developed epigastric discomfort onset 6 hours prior to admission 6/10 associated nausea, activity intolerance and orthopnea. denies diaphoresis. Onset at rest. Relieved with one NTG. Received IV NTG, Plavix and Metoprolol in ED. 2 set negative weaned of NTG IV and transferred to tele.
PMH
 Rheumatic fever as a child
Coronary artery disease, MI X 2 Diabetes Type 2
Diabetic Angiopathy
Allergies
 Aspirin, IV contrast
Surgical History
denies 
Current Meds
Plavix 75 mg po daily
Diltiazem hydrochloride CD PO 360 mg daily
Glucophage 1000 mg PO BID
Lantus 20 units at bedtime
Social History
 retired office worker, widowed lives alone, 2 children out of state, non smoker
Family History
Mother- breast cancer, Father stroke 
PHYSICAL ASSESSMENT
Neurologic/Psychiatric
No c/o headache, slurred speech, weakness, or numbness. Alert and oriented to person, place, time. Cooperative. Speech clear, appropriate, posture relaxed. Recent/remote memory intact. Cranial nerves II-XII intact. Sensation to pinprick, light touch intact. Motor: no atrophy, weakness or tremors bilaterally.
Head/Eyes/Ears/Nose/Mouth/Throat
Normocephalic, atraumatic. Facies symmetric, no weakness or involuntary movements noted.
No ptosis, no lidlag, discharge PERRLA.
Cardiovascular
No c/o chest discomfort No JVD. No heaves, no thrills. Heart sounds: S1, S2 no S3 S4 gallop or murmurs. Regular sinus tach on cardiac monitor no weight gain noted, maintained on I/O
Peripheral vascular
Color pink, no lesions, varicosities present, symmetric bilaterally. No Hair present. Edema noted to bilateral extremities , denies calf tenderness, all peripheral pulses present, no changes in temperature. Capillary refill < 2 seconds. Seq Teds in use
Respiratory
No c/o difficulty breathing. .Respirations even and unlabored, no use of accessory muscles. Trachea midline. Chest symmetric, AP diameter not increased. No tenderness on palpation. Lung fields resonant. Lungs clear to auscultation, no adventitious sounds. Po 98 % on RA
Gastrointestinal
No abdominal pain. Abdomen flat, symmetric. No lesions, herniations, gas patterns, venous patterns or pulsations. Normoactive bowel sounds in all quadrants. Tympanitic to percussion. Abdomen soft nontender. Femoral pulses present bilaterally. No lymphadenopathy. No CVA tenderness. Awaiting endocrinology for diabetic orders capillary blood sugar 126 om arrival
Musculoskeletal
No joint pain, tenderness, Moves all extremities. Initiated falls precaution
Skin
Skin pink warm dry to touch. No lesions, hyper/hypopigmentation. Hair even distribution, texture, no pest inhabitants. Nails no clubbing, cyanosis, and discoloration. Saline lock 20 gauge RFA dsg DI no r/s/p/w
Orders
Care Plan
P&P
Daily Med
Medication
Dose
Route
Frequency
Start
Stop
Clopidogrel
75 mg po
daily
XX/XX/20XX
Metoprolol
25 mg
q 6 hours X 48 hours
My stomach is burning. Can you give me some Maalox or something?
EMAR
action
Pt Tx
Call HCP
Call RRT
Coaching case questions