Mr. R Case

630 Words3 Pages
Mr. R is a 76yr old male who lives with his family, has complained of daily episodes of chest pain with palpitation for the last 2 months, has been non-compliant with medications for 2 months and has had a decreased oral intake. Mr. R also complained of increased shortness of breath and unable to mobilizes due to being “out of breath” and felt fatigued when walking a short distance, he also complain of burning whilst urination, becomes distressed and therefore suffers a panic attack which are relieved with reassurance. Mr. R has excessive sweating at times, at rest, and has also noted over the last 2 months he has overall swelling to his body and a persistent cough with increased palpitations at night and regular falls with “blackouts”…show more content…
R’s past medical history includes acute renal failure, removal of gallbladder stones, hypertension, angiograms x 3, CABG in 1984, arthritis, prostate cancer with bony metastases, AMI 2004 and panic attacks. Mr. R’s current medications include Slow K, Lasix, Losec, Zoladex, Pravachol, Plavix, Cosudex, Coversyl, and Zyloprim. Mr. R is allergic to morphine At 1345hrs following episodes of chest pain radiation to his left arm since 0100hrs. Mr. R called an ambulance in which he was transported to Hornsby hospital. Mr. R described his chest pain as tightness in his chest and rated pain 8/10 he was given 300mcg of anginine and 300mg of aspirin, oxygen was applied, the pain was relieved slightly, rating the pain 6/10 then 1/10 enroute to hospital. On arrival to Hornsby Hospital at 1410hrs, Mr. R was hypotensive 80 systolic, he was given a 250ml bolus of normal saline, an ECG was recorded which showed Mr. R was infracting, Clopidogrel 300mg per oral was given and Heparin 5000unit via intravenous infusion was commenced, urgent transport was organized, at 1440hrs Mr. R was transport to Royal North Shore Hospital emergency…show more content…
R included continuous cardiac monitoring with daily ECG’s as monitored in AF with frequent etopic beats, arrhythmias and right bundle branch block, daily bloods showed tropin rise with electrolyte imbalance, blood gasses showed severe metabolic acidosis with respiratory compensation, Trans thoracic echo to evaluate cardiac function, VQ scan for persistent shortness of breath and to rule out pulmonary embolism, oxygen 3 liters via nasal prongs to relieve shortness of breath, chest x-ray to see if pulmonary edema present, heparin infusion for infarct and until therapeutic level of >2 was reached, sublingual anginine for ongoing angina pain, low salt low fat diet, a not for resuscitation order was obtained from daughter who holds power of attorney, for pacing wires post 18 second run of asystoly Mr. R declined and requested no further surgical procedures or medical interventions to keep him alive. Ischemic dilated Cardiomyopathy, is defined as a disease of the heart muscle, the heart losses the ability to pump blood and the heart rhythm is disturbed leading to irregular heartbeats or arrhythmias. In most cases the exact cause of the muscle damage is never found. The dilated form occurs when disease affected muscle fibers lead to enlargement or dilation in one or more chambers of the heart. Therefore this weakens the heart’s pumping ability. The heart tries to cope with the pumping limitation by further enlarging and stretching in a process

More about Mr. R Case

Open Document