Question

Perfusion

L.P., a 63-year-old Asian American male, is brought to the emergency department by ambulance at 6 AM with complaints of chest tightness, shortness of breath (SOB), and palpitations. The paramedics have started an IV and O₂ at 2 L/min via nasal cannula. They also administered four chewable baby ASA and a nitroglycerin tablet, and they obtained a 12-lead ECG. L.P. is pain free on arrival but still complains of palpitations.

Subjective Data:

• PMH: History of hypertension, mitral valve prolapse with mild regurgitation, heart failure, and type 2 diabetes.
• Medications: Lisinopril (Prinivil) 10 mg/day PO, metoprolol (Lopressor) 50 mg PO BID, ASA 81 mg/day PO, furosemide (Lasix) 40 mg/day PO, and glipizide (Glucotrol) 5 mg/day PO.
• Health Perception–Health Management: L.P. denies any previous history of chest pain or CAD. He was feeling fine until this morning when he awoke and experienced SOB, chest tightness, and palpitations while walking to the bathroom. He became frightened that he was having a heart attack, so his wife called 911. Denies smoking or alcohol intake. SOB and chest tightness are now gone, but he continues to feel palpitations.
• Elimination: Denies any edema. States takes Lasix in the morning and typically “passes urine until lunchtime.” Denies nocturia.

Objective Data

• BP 100/54, apical-radial pulse 154, pulse irregular, respiratory rate 20, temperature 98.2° F (36.8° C), O₂ saturation 94% on room air
• Awake, alert, and oriented ×3
• Lungs clear on auscultation; systolic murmur present
• Heart monitor shows atrial fibrillation with a rapid ventricular response
• +1 pedal pulses bilaterally
• No peripheral edema, jugular venous distention, or heaves noted

Discussion Questions

1. What should be included in the physical assessment?
2. Which physical assessment findings are of most concern to you?
3. Based on the results of the subjective and physical assessment findings, what diagnostic studies do you think will be ordered for L.P.?

Answer 1

●The physical assessment should include cardiovascular system assessment with observation, palpation and auscultation

Observation :jugular venous distention helps to ide tifythe central venous pressure

Palpation:to assess the point of maximal impulse and identify any ventricular dysfunction

Carotid artery palpation is also assessed to rule out blood supply to brain

Auscultation:to be dine at pulmonic area,aortic area,tricuspid area and mitral area

Intake and output measurements to rile out fluid overload or deficit

Respiratory susten for fluid collections or backup

CNS for consciousness

●The physical assessment which concerns most are

• The blood pressure is low especially the diastolic pressure is very low which needs immediate intervention
• Tachycardia with irregular pulse
• +1 edema
• Murmur

●The diagnostic tests needed to be done are

• Cardiac markers to rule out any infarction or ischemia
• Serum electrolytes
• ABG to assess acid base balance
• Urine analysis
• CBC
• Chest X ray
• ECH
• Echocardiogram
• Coronary angiography