Pages

Friday, May 8, 2009

STEMI EKG & Angio


Prehospital 12 Lead:


Actual information from EMS patient care report:
Narative:
PT STATES HE WAS ASLEEP AND WAS WOKE OUT OF A SLEEP BY SEVERE SUBSTERNAL CHEST PAIN, 10/10 ON PAIN SCALE. PT STATES HE TOOK THREE OF HIS OWN NITROGLYCERIN AND CALLED 911. PT STATES AT TIME OF INITIAL EMS ASSESSMENT PATIENT'S PAIN WAS A 2/10 ON PAIN SCALE. PT DENIES NAUSEA, DIAPHORESIS, VOMITING, OR SHORTNESS OF BREATH. PT IS ALERT AND ORIENTATED. PT ADMITS TO DRINKING APPROX 5 ALCOHOLIC DRINKS THIS EVENING, AND STATES HE DID TAKE A VIAGRA THIS EVENING SEVERAL HOURS BEFORE BEDTIME. DURING INITIAL ASSESSMENT PATIENT STATES PAIN DID RE-OCCUR AND WAS NOW A 10/10, WITH RADIATION TO THE NECK AND JAW. PT IS STILL DENYING NAUSEA OR SHORTNESS OF BREATH.
Medical assessment:
Mental Status: Normal Mental Status for Patient, Oriented-Person, Oriented-Place, Oriented-Time, Oriented-Events, ; Neuro: Normal, ; Eyes: R: Reactive,; L: Reactive, ; Skin: Normal, ; Head/Face: Normal, ; Neck: Normal, ; LUQ: Normal (Soft, Non-Tender), ; LLQ: Normal (Soft, Non-Tender), ; RUQ: Normal (Soft, Non-Tender), ; RLQ: Normal (Soft, Non-Tender), ; GU: Normal, ; Cervical: Normal (No Pain or Deformities), ; Thoracic(back): Normal (No Pain or Deformities), ; Lumbar: Normal (No Pain or Deformities), ; Extremities: Upper R: Normal, ; Upper L: Normal, ; Lower R: Normal, ; Lower L: Normal, ;

Chest/Lungs: Chest Pain/Pressure (Non-reproducable), SEVERE PAIN 10/10 RADIATING TO NECK, AND JAW;
Vitals:
01:02 92/60 80 RR 20 Normal 97 Low O2 2/10 Right Arm (Supine)
01:12 88/60 78 RR 20 Normal 100 High O2 10/10 Right Arm (Semi-Fowlers)
01:24 86/56 72 RR 22 Normal 100 High O2 10/10 Right Arm (Supine)
01:31 118/63 72 RR 20 Normal 100 High O2 10/10 Right Arm (Trendelenburg)
01:38 108/60 68 RR 20 Normal 100 High O2 8/10 Right Arm (Trendelenburg)

Angiogram Pre & Post-treatment: Right Anterior Oblique View


Proximal LAD lesion resulting in decreased blood flow to anterior & septal walls.

ACS Feedback Form: Door to balloon time was 77 min.

No comments:

Post a Comment