Mr: 769162745

Neighborhood Hospital
Emergency Department Record

Date: Thursday Arrival Time: 0912 Method of Arrival: EMS
Condition upon arrival: Poor
Triage Assessment Time: 1832
Information Obtained From: patient
Name: Ocampo, Danilo
Vital Signs: T: 36.7C RR: 26 HR: 111 BP: 91/42 MAP 57 O2 Sat: 99% 2L Pain: 10/10
Gender: M Race:
Marital Status: Married Occupation:
5’ 7’’ Wt:
LMP: N/A Pregnant: N/A Allergies:
Medications: Metoprolol, lisinopril, aldactone, furosemide, potassium when taking furosemide, aspirin, isosorbide dinitrate, and
nitroglycerin
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 Examination Findings:
Social Hx:
Immunizations:
Anxious and diaphoretic with increased work of breathing; HRRR, frothy pink sputum with cough. Bilateral lower lobe crackles noted anterior- and ETOH: none Triage Interventions:
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 Level: A Disposition:
Triage Nurse Signature: Ron Litrell, RN

Nursing Assessment: Time: 0925 ER Bed: Cardiac Room
Mental Status/Neuro
Head/Neck:
anxious, follows commands appropriately.
Respiratory:
Cardiovascular
Eyes/Ears:
S1, S2; no murmurs or extra heart sounds. Abdomen:
GU/Genitalia
Musculoskeletal:
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
Physician Assessment/Notes
Time: 0930
HPI
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
Neuro: Anxious but oriented.
ENT: Normocephalic, PERRLA- 3mm.
CV: HRRR; no murmurs; pulses +1 thready; cap refill 3 seconds.
Resp: Shallow, rapid respirations with bilateral crackles noted.
GU: Negative.
Mus/Skel: Symmetrical and equal.
Impression: Acute MI, worsening heart failure.

Physician Orders:
Physician Notes
0950- 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. 1010- Cardiology consult arrives. Dr. Cox states pt. is mostly likely in heart
failure due to non-adherence to medication regimen. Dobutamine gtt. 1035- Patient having increased shortness of breath. Intubated with 7.0 ETT,
secured at 22cm. Vent settings- SIMV rate 16, FiO2 100%, PEEP 8, Pressure 1045- 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.
Consultation: Cardiolgy Arrival Time: 1010
Diagnosis: Acute MI progressing to cardiogenic shock
Disposition: Deceased

Physician Signature: James Gordon, MD
RN signature: Sjori Kauffman, RN
RT signature: Jenna Melendrez, RRT
Emergency Department Nursing Flow Sheet
Assessment/Response
Initials
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
Fluid Intake
Fluid Output
Type Amount
Running Time
initated


Discharge Instructions: N/A
Disposition:

Time Discharged from ED: N/A

RN Signature: Sjori Kauffman, RN
Signature:
Cardiopulmonary Resuscitation Record
Date: Thrusday Location: ED- Cardiac room Service: Emergency Medicine
Witnessed arrest: X Unwitnessed arrest:___ Respiratory arrest:___ Cardiac arrest: X
Code Chronology
Time Code Event Recognized: 1045 Time CPR started: 1045 Code Team Called? No Time Code Team Called: N/A

Time Code Team Arrived: N/A AED Time: 1048 Code Status: Full Number of Shocks: 4

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__________
Respiratory Assssment/Interventions:
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: No
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
Recorder:

Source: http://www.pearsonneighborhood.com/pdf/lvl2/DaniloOcampoL2W10.pdf