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2/13/1999 18:40 St. Jennifers Med Center - Dr. Croaker Admit 47-year old male admitted to TA 222 via cart from ER. Patient experienced some mid-chest tightness. No nausea and vomitting, no radiation of pain. Did experience some dizziness and irregular heartbeats were felt. Initially pain was 2/10. That resolved with O2. History of Diabetes. Normal sinus rhythm on cardiac monitor. No edema. BP 154/98. Heart rate low 100's, patient oriented to room. O2 on at 2 and 1/2 liters via nasal cannula. O2 saturation 93%. Lungs bilateral clear. Occasional MPC. Has had bronchitis last week and flu. Was on ammoxycilin. Given supper tray. Ate 100%. IV changed to D5 normal saline at 125 cc's per hour.

2/13/1999 21:15 St. Jennifers Med Center - Dr. Croaker Assessment: BP 130/100. Pt still has little chest tightness. NTG gr 1/150 SL per protocol
Assessment: Med. with 1 nitroglycerin grain. 1/150th O2 4 liters. O2 saturation 96%.
2/13/1999 21:20 St. Jennifers Med Center - Dr. Croaker Chest tightness gone. BP 104/73
2/13/1999 22:00 Patient pain free, watching TV

2/14/1999 St. Jennifers Med Center - Dr. Croaker Medication Administration Record Medication: Zestril 10 mg po qd. ASA 1 po qd
2/14/1999 St. Jennifers Med Center - Dr. Croaker IV Flowsheet Solution D5 normal saline.
2/14/1999 St. Jennifers Med Center - Dr. Croaker Care Pathway - Angina - Acute 3
2/14/1999 00:05 St. Jennifers Med Center - Dr. Croaker Patient Care Record Eyes closed, snoring. Turned to side. O2 sats 90's.
2/14/1999 02:00 St. Jennifers Med Center - Dr. Croaker Tylenol 325 mg 1-2 po q 4 hours prn minor pain.
2/14/1999 02:00 St. Jennifers Med Center - Dr. Croaker Patient Care Record Denies chest pain or tightness. Lungs clear. Slight decrease. O2 saturation 97% with 3 and 1/2 liters of O2. BP 115/71. Heart rate 86 regular. Complained of slight headache. Tylenol given.
2/14/1999 03:00 St. Jennifers Med Center - Dr. Croaker Patient Care Record Looks asleep. Respirations even, easy.
2/14/1999 06:00 St. Jennifers Med Center - Dr. Croaker Continued to look asleep. Respirations even. Cardiac monitor normal sinus rhythm 70's to 90's without ectopic.
2/14/1999 07:30 St. Jennifers Med Center - Dr. Croaker Admits to dyspnea with exertion with or without Oxygen.
2/14/1999 08:30 Up to bathroom - felt shortness of breath and slight chest tightness. Nurse sat with patient. Became calmer. Said he felt afraid.
2/14/1999 09:30 St. Jennifers Med Center - Dr. Croaker Patient Care Record Up at bedside to bathe self. Took his time. No dyspnea or pain.
2/14/1999 10:15 St. Jennifers Med Center - Dr. Croaker Patient Care Record IV discontinued. Gelco intact. Intends to continue use of snuff (1 box per week). Plans to cut back on coffee. Angina and nitrglycerine reviewed. Sheets given re ischemic heart disease. Expressed good understanding. Discharge W/C for home. Wife has all belongings with patient. Has prescription and hand-outs. No pain or dyspnea.
2/14/1999 11:30 Have noted no ectopy this a.m. When lab came to draw 10:00 a.m. CPK, patient refused as he already had discharge orders.
ADDENDEM: Written at 11:30. 251
2/14/1998 10:20

Patient Discharge Instructions
Medication:
Glucotrol one qd.
Zesteril 10 mg. one qd.
Nitroglycerin sub lingual for chest tightness
Call 911 if pain reoccurs
Angina hand out-check mark. As usual-check mark.
Restrictions: none
Return to clinic 2/15/98
Contact physician if you experience angina not relieved by Nitro one tablet q 5 minutes X 3.