Important medications is this patient missing

Reference no: EM133625836

Case study : S: Mr. C is a 68 yo male who came to the ER complaining of chest pain and SOB. B: Mr. C has a hx of HTN, CAD, CKD, DM2, hyperlipidemia, neuropathy pain, low back pain, lumbar stenosis, and gout. He is a farmer and was found on the ground clenching his chest. The workers called 911 and administered Aspirin 325po and chewed. When he arrived to the ED, they found elevated troponin and EKG indicate a STEMI. A code white was issued and was urgently sent to cathlab. After getting a left heart Cath, he was transferred to ICU with a PA catheter with a low CO index. EF of 38%He got two PCI stents on the RCA and Left Circumflex. A: Neuro: Alert and oriented. Comfortable. Pulmonary: He is on O2 2L NC sating at 95%. Lungs has crackles bilateral on the lower base but clear on all other lung fields. Chest X rays shows Bilateral infiltrates but PA catheter is in the right location. Cardiac: He has an A line on the right radial and PCI was entered through the left femoral site with a dressing. He has no murmurs and heart sounds are regular. EKG still shows ST elevated but in the 110's. BP consistently shows 89/54 (55). RR 14. He is only on fluids 0.9% NS at 150cc/hour with only 200ml given. He has a central line placed in the Cath lab. Abdomen: He abdomen is soft, non distended and without any hernias. Bowel sounds are active on all quadrants. GU: He is incontinent but has no had any urine output since he came to the ER. Skin: He has only has 3 fingers on the left hand and full used fingers on the right hands. He had a hx of amputation d/t DM. Psych: He is calm and alert. Compliant Labs: CBC WNL; CMP: Creatinine 1.5--->1.8, BUN 55--->80. GFR 55--->40. K 3.8---->3.4 Troponin 14.5------>16.5. BNP 900---->1300. before cathlab----->after cathlab. Diagnostics: CVP 12mmhg. PAWP 21. PA 50/35. R: Continue with NS. We need to bring his BP up. There are no physicians orders yet. He just got here. So I stabilized him for you.

Questions:

1. What are 3 VERY important medications is this patient missing?

2. How would you call the physician and ask for order? Name 3 important orders you need.

3. What are three IMPORTANT assessment you need for follow up on?

Reference no: EM133625836

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