Emergency Department Record
Thursday Arrival Time:
0912 Method of Arrival:
Condition upon arrival
Triage Assessment Time
Information Obtained From
Vital Signs: T:
91/42 MAP 57 O2 Sat:
99% 2L Pain:
5’ 7’’ Wt:
Metoprolol, lisinopril, aldactone, furosemide, potassium when taking furosemide, aspirin, isosorbide dinitrate, and
Reason for Seeking Care:
Chest pressure, cough productive of
Past Medical Hx:
Significant Family Hx:
frothy, pink sputum. Fatigue and shortness of breath x few weeks, Hypertension, myocardial
Anxious and diaphoretic with increased work of breathing; HRRR, frothy
pink sputum with cough. Bilateral lower lobe crackles noted anterior- and ETOH: none
Oxygen .50 NRB, Morphine 4mg IVP, Nitrogycerine 1 tab SLx1, aspirin 325mg POx1, Furosemide 40mg IVPx1, stat 12-lead ECG.
#16G IV catheter placed (L) AC, #18G IV catheter placed (R) FA, foley catheter placed. Labs- CH12, CBC, ABG, UA, Digoxin
level, cardiac enzymes sent.
Triage Nurse Signature: Ron Litrell, RN
Nursing Assessment: Time:
0925 ER Bed:
Cardiac Room Mental Status/Neuro
anxious, follows commands appropriately.
S1, S2; no murmurs or extra heart sounds.
Abd flat, + bowel sounds all 4 quadrants;
moves all extremities with equal strength.;
soft, non tender, no distension or guarding.
RN signature: Sjori Kauffman, RN
Patient reports shortness of breath and angina off and on for few weeks. Increased lower extremity edema reported for few weeks, also
noted on arrival. Has not been taking medications as prescribed for one week since wife’s illness. Pt. reports increasing fatigue and
new onset chest pain, stated 10/10 on pain scale, with cough productive of pink, frothy sputum.
Pt. has hx significant for hypertension, MI, angina, and class 2 heart failure. Examination Findings
Anxious but oriented.
Normocephalic, PERRLA- 3mm.
HRRR; no murmurs; pulses +1 thready; cap refill 3 seconds.
Shallow, rapid respirations with bilateral crackles noted.
Symmetrical and equal.
Acute MI, worsening heart failure.
ECG shows significant ST elevation noted in V1 to V4. Lab results
returned as follows: CBC- WNL, CH12- K+- 3.6, Na- 136, CO2- 22,
Chloride- 100, BUN- 12, Creatinine- 0.8. ABG: pH- 7.28, CO2- 55, PaO2-
78, Bicarb- 24. UA- WNL, Digoxin level-0.1ng/ml. Cardiac enzumes: CK-
336 U/L, CK-MB- 10.8IU/L, Troponin- 1.0ng/ml.
Cardiology consult arrives. Dr. Cox states pt. is mostly likely in heart
failure due to non-adherence to medication regimen. Dobutamine gtt.
Patient having increased shortness of breath. Intubated with 7.0 ETT,
secured at 22cm. Vent settings- SIMV rate 16, FiO2 100%, PEEP 8, Pressure
Patient into v-fib. Resuscitation efforts started. Please see code sheet.
25mcg IVP, Vecuronium 10mg IVP, and Etomidate 20mg IVP-for intubation. Stat chest xray for tube placement, stat ABG.
Cardiolgy Arrival Time:
Acute MI progressing to cardiogenic shock Disposition:
James Gordon, MD
RN signature: Sjori Kauffman, RN
Jenna Melendrez, RRT
Emergency Department Nursing Flow Sheet
Morphine 4mg IV for chest pain. ECG done. Pt. c/o
Pt. states pain slightly improved post Morphine. SOB
unchanged Pt. remains anxious. Ativan 1mg IVP given for anxiety. Nitroglycering 1 tab SL given for chest pain.
Pt. states slight improvement, appears more
comfortable at this time, now slightly confused- reorients easily. Chest pain continues, “crushing” per pt. when asked.
Pt. states pain “horrible” when asked. Pt becoming
combative with increasing confusion. Morphine 2mg IVP given per Dr. Gordon. Pt. having frequent, multifocal PVCs.
Dobutamine gtt started at 5mcg/kg/min. per Dr. Cox,
cardiology. Pt having obvious respiratory distress, states “yes” when asked if he wants a breathing tube placed.
Pt. intubated by Dr. Gordon on 1st attempt. Ativan 2mg
IVP, Fentanyl 25mcg IVP, Vecuronium 10mg IVP, and etomidate 20mg IVP prior to intubation.
Pt. on vent per Jenna, RRT. See respiratory flowsheet.
Pt. remains unresponsive, dobutamine gtt increased to
8 mcg/kg/min. to increase MAP to 65. Chest xray
Pt. into V-fib, 0 pulses. Dr. Gordon at bedside. See
Time Discharged from ED:
RN Signature: Sjori Kauffman, RN
Cardiopulmonary Resuscitation Record
ED- Cardiac room Service:
Witnessed arrest: X Unwitnessed arrest:___ Respiratory arrest:___ Cardiac arrest: X
Time Code Event Recognized:
CPR started: 1045 Code Team Called?
No Time Code Team Called
Time Code Team Arrived:
N/A AED Time: 1048 Code Status:
Full Number of Shocks:
Presenting Hx R/T Code:
chest pain, shortness of breath, cough productive of pink, frothy sputum. Hx. of heart failure, hypertension, MI.
On cardiac monitor prior to arrest? Yes Intubated prior? Yes Admitting Dx: acute MI, heart failure
Glasgow Coma Scale: Pupil Guage: 3 4 5 6 7 8 (mm)___ Pupils: Equal reac Fixed/No reac Unequal__________
Intubated during code? No Intubated by: Dr. Gordon Time of Intubation: 1035 Tube placement: 22cm at teeth
Spontaneous ventilation: No Size of ETT: 7.0 Oral X
Nasal___ Bilateral breath sounds: Yes
Airway ETT X
LMA___ Number of intubation attempts: 1- prior to code
Ambu bag w/ 100% O2? Yes Comments:___________________________________________________________________________ Prior IV Status
Initiated IV Status:
External Pacemaker Used:
Time Rhythm Joules Med/Dose/ Response Pulse BP
Sp CPR BVM Fluid Comments
Time Site FiO2 pH PaCO2 Pa02 HC03 %Sat Other Lab
Post Arrest Status
Expired: Yes Time: 1057 Pronounced by: Dr. Gordon
Family Notified? Yes Name: Kristina- niece By: Dr. Gordon
Autopsy Requested? Yes Requested By: Kristina- niece
Donor Services Notified? Yes Time: 1115 By: Dr. Gordon
Print Name Signature
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CURRICULUM VITAE Barry J. Goldstein, M.D., Ph.D., F.A.C.E. Academic Office: Room 349 Alumni Hall, 1020 Locust Street, Philadelphia, PA 19107 Clinical Office: Suite 600, Walnut Towers, 211 S. 9th Street, Philadelphia, PA 19107 Phone: (215) Fax: (215) Medical License Current Position: Director, Division of Endocrinology, Diabetes and Metabolic Diseases, Jeffer