Acute Care Case Study
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Name: Bernadette Carter
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Age: 68 years old
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Height: 165 cm
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Weight: 75 kg
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Gender: female
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Allergies: Nil Known
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Physician: Dr Clive Charmers
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Past History: Hypertension, AF, AMI (2014), GORD
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Current History
Bernadette is a 68-year-old female admitted to the healthcare facility for a scheduled Coronary Angiogram. She presents with increasing fatigue and shortness of breath, nausea and vomiting for investigation. Bernadette lives at home with her husband and is normally independent with ADL’s.
Ward Admission 18/08/20 0630
- Urinalysis SG 1.030, pH 7.3
- Peripheral pulses palpable, obvious bilateral oedema, wound to left malleolus.
- Conscious level - alert and orientated to time, person and place
- BP 148/93 HR 118 bpm (irregular) RR 22/min SpO2 93% RA T 36.5c
Bernadette has an IVC inserted, groin shaved and she is gowned. Fasted since 2400.
Angiography report:
Procedures Left heart catheterisation & coronary angiography. Vascular Access Location: right femoral artery. Sheath: 6Fr (right femoral). Contrast: Iopamidol: 140 ml
90% occlusion RCA and circumflex arteries. 70% occlusion anterior intraventricular artery. C. Chalmers
Handover 0845 from procedure staff
Peripheral pulses palpable, CWMSÖ Right foot / Left foot
Pain 1/10
Alert and orientated to time, place and person
Right groin puncture reinforced – dry and intact
IVT Ö
Post procedure MO Orders:
- Routine post angiography observations
- LWD
- Encourage PO fluids
- FBC
- Strict RIB flat for 4/24
- Discontinue IVT after 3rdflask
- ECG Chalmers
IV Orders:
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Flask #
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Fluid
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Rate
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MO’s Signature
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Date/Time Commenced
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Signatures
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1
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Hartman’s 1000mls
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2/24
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C. Chalmers
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18/08/2020
0700
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Angio
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Angio
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2
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Hartman’s 1000mls
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4/24
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C. Chalmers
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18/08/2020
0900
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HW
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MM
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3
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4% Dextrose & 1/5 N/Saline 1000mls
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6/24
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C. Chalmers
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4
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N/Saline 1000mls
with 100mmol NaHCO3
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6/24
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C. Chalmers
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18/08/20 0900
Pain 1/10
Peripheral pulses palpable, C (cool) WMSÖ Right / left foot, pitting oedema bilaterally
Alert and orientated to time, place and person
Right groin dressing reinforced +++
IVT Ö
18/08/20 0915
Pain 1 – 2 /10
Peripheral pulses palpable, C (cool) WMSÖ Right / left foot, pitting oedema bilaterally
Alert and orientated to time, place and person
Right groin dressing dry and intact
Bi basal crackles auscultated, frequent moist cough
IVT Ö
18/08/20 0930
Pain 1 – 2 /10
Peripheral pulses palpable, CWMSÖ Right foot, pitting oedema bilaterally
Alert and orientated to time, place and person
C/O “indigestion pain”
Right groin dressing dry and intact
Frequent moist cough,
O2 2L NP applied
IVT Ö
Pathology Results 18/08/2020 0900
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Test
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Result
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Normal Ranges
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Se Na2+
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125 mmol/L
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135-145 mmol/L
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Se K+
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6.1 mmol/L*
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3.5 – 5.0 mmol/L
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Se Ca-
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2.10 mmol/L*
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2.10 – 2.60 mmol/L
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Se PO4
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1.5 mmol/L*
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0.8 – 1.5 mmol/L
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Total Protein
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69 g/L*
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62-80 g/L
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Se Creatinine
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0.26 mmol/L*
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0.06 – 0.12 mmol/L
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Se Urea
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10.0 mmol/L*
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3.0 – 8.0 mmol/L
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eGFR
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40 mL/min/1.73m2
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> 90 mL/min/1.73m2
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Platelet
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180 x 109 /L*
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(150 – 400 x 109 /L)
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Haemoglobin
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130 g/L*
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120-180 g/L
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Partial PT
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13 seconds*
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11-15 seconds
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