H and P with Update
Jack Sparrow is a 50 y.o white male. Full code PMH: CHF, IDDM, GERD and constipation.
He was admitted through the ED this am with acute respiratory distress, c/o of SOB, diffuse chest pain and anxiety. Symptoms started around 3 am during a bar fight in which he sustained a small abdominal wound not requiring sutures and a head injury secondary to a bottle over the head. Both wounds were very dirty.
Plus one edema in ankles. Peripheral pulses +3/3. AAO x3, pleasant and smiling despite his obvious discomfort, lives alone, no living relatives, significant other is out of town. Neuro CN II - XII intact. GI/GU and MS wnl.
He is treated with digoxin and Lasix at home. Takes Regular and NPH insulin every am for his diabetes however there is some question about his compliance. He admits to a poor diet. Pt is underweight at 140 lbs. His EKG showed no changes, normal sinus rhythm, Troponin levels were not elevated. The pt received Morphine 2 mg IV for chest discomfort just prior to transport. Pt for CT scan of the Chest to r/o PE.
Bedrest. 1800 cal ADA diet.
You do not appreciate any significant issues on your head to toe exam. You are going in to pass your morning meds. You have taken your VS and checked your labs. (Review these results and consider thier implications.)