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 Report
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. | |||||||||