Stemi Essay

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Pt: 44 y/o WM CC: Pt was short of breathe and gets tired quickly. Rapid heart rate and feels a little weak. HPI: Patient presents with mental status changes and was found to be in atrial fibrillation with rapid ventricular rate. He was on medication but has not been taken them for over a year because he thought he was all better. Patient is visiting aunt and was brought into the ER and was mini-altered. Patient was given Geodon and Haldol to calm him and EKG was done. EKG showed A. fib with heart rate as high as 170. He was put on Cardizem drip and admitted for further evaluation. The patient denies symptoms of any chest pain, fever, nausea or vomiting. Patient was then transferred to Jackson General for further evaluation. PMH: Hypothyroidism, Schizophrenia, Arrhythmia PSH: Alcohol use, denies tobacco use and illicit drugs. The pt has been out of work for over a year now. Had a tonsillectomy Allergies: NKDA FH: Patient unaware of any family history Homes Meds: None Vitals on Admission at Jackson General: Blood pressure | 80/60 | Pulse | 75 BPM | Respiratory Rate | 18 | Temp | 36.9 C | Oxygen saturation | 100 % with 2 L of oxygen | Weight | 90.9 kg | Height | 205.70 cm (81 in) | CrCl | 145.62 | PE on admission: General: alert, no acute distress Skin: warm, dry Head: Normacephelic Neck: supple CV: Normal peripheral perfusion, no edema, irregular rhythm Pulmonary: lungs are clear, respiration non-labored, breath sounds are equal Musculoskeletal: normal Neurological: Alert and oriented to person, place, time and situation Psychiatric: Cooperative, appropriate mood and affect Labs: | 2/3/12 | 2/4/12 | 2/5/12 | 2/6/12 | 2/7/12 | Na | 142 | 138 | | 140 | | K | 3.8 | 3.8 | | 3.8 | | Cl | 105 | 108 (H) | | 105 | | CO2 | 22.8 | 24 | | 26 | | Anion gap | 18 (H) | 9.8 | |

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