S: 70 year old Female present to the ER with Lab Values/Diagnos c Tests

complaints of heart racing every me she

Conceptual Care Map
stands up and moves. The pa ent reports no Troponin- 0.06 AST-113
Student Name: Rachel Miller Pa ent: ER
shortness of breath or dizziness.
Age: 70 y/o Gender: Female Admission Date: 11/1/23 Hemo- 12.5 ALT-122

B: The pa ent has a past medical history of CODE Status: FULL Allergies: NKA Braden Score: Diet: REG Ac vity: Independent
Hema- 37.8 BUN- 13
Dermatomycosis. Started taking Prednisone
Weight: 74.9g Height: 167.6cm Religion: Chris an IV Therapy: IV R AC saline RBC- 4.18 Creat- 0.60
for it. She has a past surgical history of
breast biopsy. She quit smoking 30 years ago. locked
WBC- 10.40
A: Pa ent well-appearing, no distress.
Mental status appropriate for age, Eyes: no Na- 137
discolora on, devia on or discharge, Lung:
no adven ous sounds, Heart: Regular
Admi ng Diagnosis/Chief Complaint—> Tachycardia K-4.3 Ge ng ECHO b/c of
rhythm, Tachycardia, S1 and S2 heard, Troponin level
Vascular: strong peripheral pulses, no
thromboli c treatment currently, GI: Patho Flow Diagram
abdomen so , non-tender, norma ve, GU:
urine yellow and clear, Skin: warm, dry, Interdisciplinary Collabora on
no abrasions, cuts, or Sinus Tachycardia
wounds. Cardiology, Lab, Physicians,
Causes
Nurses
BP: 128/88 HR: 130 R: 18 T:
98.5F O2: 97%
Hemodynamics: Treatment/Procedures:
R: Recommend ECHO for further work up. Hypovolemia Metabolic:
Admi ed for ECHO to further inves gate CT Angiogram(nega ve for PE),
Pulmonary Embolism Fever
Tachycardia and the source of the Chest X-ray(nega ve), ECG (showed
Tamponade Hyper/Hypoglycemia Sinus Tachycardia)
Medica ons Cardiogenic/ACS Pheochromocytoma
Hypoxia
Escitalopram (Lexapro) 10mg tab Psych./Soc./Economic Data
(used for anxiety and decreases HR) Other:
Substance: Pain Private residence, Married: Wife
Folic Acid (Folvite) 1mg tab daily Ingestion Inappropriate Sinus supports pa ent and the problem
Withdrawl doesn’t concern her much. They have
(increase folate levels, preven ng Tachycardia
Iatrogenic (Albuterol) come in for his Tachycardia before. No
folic acid anemia) Anxiety smoking
Methotrexate 2.5 mg tab (for Physicians are working to find the source of the patient’s tachycardia Discharge Teaching Needs
dermatomycosis)
Admi ed into the hospital for ECHO,
Past Medical/Surgical History
Prednisone (Deltasone) 30mg so no need for discharge teaching
tab/day (for dermatomycosis) Dermatomycosis, Breast Biopsy currently. Cardiologists are s ll
working to gure out the source of
tachycardia and how to proceed.
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