Summary Finlay Watson DOB 15/06/1967

Patient Summary

MRP	Hart
Admit Date	T-3 days (3 days ago)
Primary Diagnosis	NSTEMI
SECONDARY DIAGNOSES

Implanted Device
Blood Consent			Blood Type:
Aggression	History of Violence: n/a		Physically Aggresive:
Behaviour	Verbally Aggresive: n/a		Violence Prevention Toolkit:
Religion	unknown
OXYGEN			SUCTION
SURGERY	n/a
DRAIN
WOUND
Isolation	n/a		Code Status:	Link to MOST
Substance Use	n/a		Last Use:
Alcohol Use	occasional		Last Use:	x 1 week
Tabacco Dependence:		n/a	Last Use:	20 years ago
ALLERGIES	Reaction type:	penicillin /rash		Severity:	moderate
	Reaction type:			Severity:
	Reaction type:			Severity:
DIET

Shift	Neuro	Cardio	Resp	GI	GU	Skin	Wound	Nutrition	In/Out
Day shift (2 days ago)	GCS 15	Tele NSR	Clear	BSX4	Urinal qs	Intact	none	Cardiac diet	IV
									Adequate
NOTES:	Admitted from ER @ 1830. Able to stand and transfer with no chest pain. Ate supper, wife into visit.
	Understands importance of using call bell if any CP/ Tightness/ SOB. Using urinal for voids.

Shift	Neuro	Cardio	Resp	GI	GU	Skin	Wound	Nutrition	In/Out
Night Shift (2 days ago)	GCS 15	No CP	Clear	BSX4	Voids	Intact	None	no concern	IV
									Adequate
NOTES:	BP 155/90 pre cardiac meds deceased 125/75. Denies any CP. Slept intermittently.
	Up sitting @ bedside and wlaked to BR x 1 with no issues.

Shift	Neuro	Cardio	Resp	GI	GU	Skin	Wound	Nutrition	In/Out
Day (y’day)	GCS 15	Tele	Clear	no BM	Voids	no concerns	none	Cardiac	IV
									Adequate
NOTES:	Seems a bit anxious today- states he is worried about work. On the phone ++. BP increasing
	this morning but responded to meds. Denies any CP. Asking if he could go home then go for angio.
	Explained risks. Wife in x 1. Ambulating around room/ BR no concerns.

Shift	Neuro	Cardio	Resp	GI	GU	Skin	Wound	Nutrition	In/Out
Night (last)	GCS 15	Tele	clear	no BM	Voids	no concerns	none	Cardiac	IV X 1

NOTES:	Slept poorly. No chest pain over night. Slept poorly d/t admission @0200, had zopiclone @ HS.
	Up to BR for voids. Wants to have a shower. New IV started to Lt arm.