Nutrition: Diet order: no added salt/low saturated fat; low cholesterol History: Appetite good. He and his wife have been trying to change some things in his diet. Wife indicates that she has been using "corn oil" instead of butter and has tried not to fry foods as often. Typical dietary intake: Breakfast: Coffee with milk and sugar Midmorning snack: Egg and cheese on English muffin from work cafeteria; 8 oz. orange juice, 2-3 c coffee with milk and sugar Lunch: Dinner: Snack: Leftovers from home; if eats in cafeteria: soup, salad, or sandwich. Had tomato soup and grilled cheese yesterday. Rice-1 c; black beans-1 c; roast pork with tomato and peppers- approx. 6 oz; cornbread-2 squares, each 2" wide Typically has chips or popcorn and 1-2 beers Food allergies/intolerances/aversions: None Previous nutrition therapy? No Food purchase/preparation: Spouse Vit/min intake: None Garcia, Jose, male, 01 y.o. Allergies: NKA Pt. Location: RM 704 Code: FULL Physician: RJ Warren Isolation: None Admit Date: 12/1 Allergies: NKA Pt. Location: RM 704 Code: FULL Physician: RJ Warren Isolation: None Admit Date: 12/1 Extremities: Normal range of motion in all four extremities. No cyanosis or clubbing or peripheral edema. Neurological: Conscious, alert, and oriented. Cranial nerves II through XII are intact grossly and symmetrically. No focal neurologic deficit. Skin: Skin is warm and dry. Mild diaphoresis. No rashes or ulcerations noted. Vital Signs: Temp: 98.6°F Orders: BP: 140/99 Pulse: 94 Height: 5'9' Resp rate: 23 Weight: 215 lbs ED: Oxygen 2 liters per NC to maintain O₂ SAT >95%; nitroglycerin 0.4 mg sublingual; aspirin 81 mg x 4 (324 mg total), to be chewed Heparin 70 units/kg bolus IVP (max dose 7500 units) Clopidogrel 600 mg oral Admission to CCU: Early risk stratification: high risk Activity: bed rest Cardiac monitor Vital signs q4h x 24 hours then q8h Diet: no added salt/low saturated fat; low cholesterol Call house officer for T>101, SBP >190 mm Hg or SBP <90 mm Hg, HR >120 bpm or HR <50 bpm, RR >30 or RR <10 Guaiac ALL stools while on heparin, LMWH, Ilb/illa inhibitor O₂: NC continue 2 L/min Please call house officer for O₂ SAT <90% Order for respiratory care O₂ SAT check q8h EKG and repeat for recurrent chest pain Troponin T/Troponin I: now and every 6 hrs x 8 times CK-MB: now and every 6 hrs x 8 times CBC, lipid profile, PTT, Chemistry (7) panel in AM-fasting Atenolol 75 mg/d Nitroglycerin 1/150 (0.4 mg) 1 TAB SL q 5 min x 3 prn chest pain; hold if: SBP <100 mm Hg PRN: Docusate sodium 100 mg po twice daily; aluminum-magnesium hydroxide 15 mL every 6 h for indigestion; oxazepam 15-30 mg po every hs prn insomnia; acetaminophen 650 mg po every 4 h for headache; magnesium hydroxide 30 mL po daily for constipation; magnesium sulfate sliding scale IV qd; call house officer if serum Mg <1.2 Hold order for creatinine >1.9 If serum Mg <1.4, give 5 g MgSO, IV; if serum Mg <1.6, give 4 g MgSO, IV; if serum Mg <1.8, give 3 g MgSO, IV; if serum Mg <2.0, give 2 g MgSO IV Patient Summary: José Garcia is a 61-year-old male admitted through the emer gency department with diagnosis of STEMI and transferred directly to Cath lab; s/p emergency coronary angiography with angioplasty of the infarct-related artery. History: Onset of disease: 61-y.o. male who noted the sudden onset of severe precor- dial pain on the way home from work. The pain is described as pressure-like pain radiating to the jaw and left arm. The patient has noted an episode of emesis and nausea. He denies palpitations or syncope. He denies prior history of pain. He admits to smoking cigarettes (1 pack/day for 40 years). He denies hypertension, diabetes, or high cholesterol. He denies SOB. Medical history: Not significant before this admission Surgical history: Surgery; cholecystectomy 10 years ago, appendectomy 30 years ago Medications at home: None Allergies: Sulfa drugs Tobacco use: 40-year history, 1 pack/day Alcohol use: 1-2 beers per day Family history: What? CAD. Who? Father-MI age 59. Demographics: Marital status: Married, Spouse name: Alicia Garcia, 59 y.o. Number of children: Daughter and two grandchildren live in the home Years education: AA degree Language: English, Spanish Occupation: IT network specialist Hours of work: 40/wk Household members: 5 Ethnicity: Mexican American Religious affiliation: Catholic MD Progress Note: General: Well-developed, overweight male in acute distress from chest pain. HEENT: Head: normocephalic and atraumatic Eyes: EOMI, fundoscopic exam WNL. No evidence of atherosclerosis, diabetic retinopathy, or early hypertensive changes. Mouth: oral mucosa pink, dentition in good repair Throat: pharynx pink without exudates Neck: soft, supple, no palpable masses. No lymphadenopathy. Cardiac: Isolated posterior MI with ST depression in V2-3. No murmurs, clicks, or rubs. Pulmonary/Chest: Lungs are clear to auscultation bilaterally. Abdominal: Abdomen soft, nontender, with normoactive bowel sounds in all four quadrants. No masses, no organomegaly. No guarding, rebound, or CVA tenderness. RLQ scar and midline suprapubic scar. A

Nutrition: Diet order: no added salt/low saturated fat; low cholesterol History: Appetite good. He and his wife have been trying to change some things in his diet. Wife indicates that she has been using "corn oil" instead of butter and has tried not to fry foods as often. Typical dietary intake: Breakfast: Coffee with milk and sugar Midmorning snack: Egg and cheese on English muffin from work cafeteria; 8 oz. orange juice, 2-3 c coffee with milk and sugar Lunch: Dinner: Snack: Leftovers from home; if eats in cafeteria: soup, salad, or sandwich. Had tomato soup and grilled cheese yesterday. Rice-1 c; black beans-1 c; roast pork with tomato and peppers- approx. 6 oz; cornbread-2 squares, each 2" wide Typically has chips or popcorn and 1-2 beers Food allergies/intolerances/aversions: None Previous nutrition therapy? No Food purchase/preparation: Spouse Vit/min intake: None Garcia, Jose, male, 01 y.o. Allergies: NKA Pt. Location: RM 704 Code: FULL Physician: RJ Warren Isolation: None Admit Date: 12/1 Allergies: NKA Pt. Location: RM 704 Code: FULL Physician: RJ Warren Isolation: None Admit Date: 12/1 Extremities: Normal range of motion in all four extremities. No cyanosis or clubbing or peripheral edema. Neurological: Conscious, alert, and oriented. Cranial nerves II through XII are intact grossly and symmetrically. No focal neurologic deficit. Skin: Skin is warm and dry. Mild diaphoresis. No rashes or ulcerations noted. Vital Signs: Temp: 98.6°F Orders: BP: 140/99 Pulse: 94 Height: 5'9' Resp rate: 23 Weight: 215 lbs ED: Oxygen 2 liters per NC to maintain O₂ SAT >95%; nitroglycerin 0.4 mg sublingual; aspirin 81 mg x 4 (324 mg total), to be chewed Heparin 70 units/kg bolus IVP (max dose 7500 units) Clopidogrel 600 mg oral Admission to CCU: Early risk stratification: high risk Activity: bed rest Cardiac monitor Vital signs q4h x 24 hours then q8h Diet: no added salt/low saturated fat; low cholesterol Call house officer for T>101, SBP >190 mm Hg or SBP <90 mm Hg, HR >120 bpm or HR <50 bpm, RR >30 or RR <10 Guaiac ALL stools while on heparin, LMWH, Ilb/illa inhibitor O₂: NC continue 2 L/min Please call house officer for O₂ SAT <90% Order for respiratory care O₂ SAT check q8h EKG and repeat for recurrent chest pain Troponin T/Troponin I: now and every 6 hrs x 8 times CK-MB: now and every 6 hrs x 8 times CBC, lipid profile, PTT, Chemistry (7) panel in AM-fasting Atenolol 75 mg/d Nitroglycerin 1/150 (0.4 mg) 1 TAB SL q 5 min x 3 prn chest pain; hold if: SBP <100 mm Hg PRN: Docusate sodium 100 mg po twice daily; aluminum-magnesium hydroxide 15 mL every 6 h for indigestion; oxazepam 15-30 mg po every hs prn insomnia; acetaminophen 650 mg po every 4 h for headache; magnesium hydroxide 30 mL po daily for constipation; magnesium sulfate sliding scale IV qd; call house officer if serum Mg <1.2 Hold order for creatinine >1.9 If serum Mg <1.4, give 5 g MgSO, IV; if serum Mg <1.6, give 4 g MgSO, IV; if serum Mg <1.8, give 3 g MgSO, IV; if serum Mg <2.0, give 2 g MgSO IV Patient Summary: José Garcia is a 61-year-old male admitted through the emer gency department with diagnosis of STEMI and transferred directly to Cath lab; s/p emergency coronary angiography with angioplasty of the infarct-related artery. History: Onset of disease: 61-y.o. male who noted the sudden onset of severe precor- dial pain on the way home from work. The pain is described as pressure-like pain radiating to the jaw and left arm. The patient has noted an episode of emesis and nausea. He denies palpitations or syncope. He denies prior history of pain. He admits to smoking cigarettes (1 pack/day for 40 years). He denies hypertension, diabetes, or high cholesterol. He denies SOB. Medical history: Not significant before this admission Surgical history: Surgery; cholecystectomy 10 years ago, appendectomy 30 years ago Medications at home: None Allergies: Sulfa drugs Tobacco use: 40-year history, 1 pack/day Alcohol use: 1-2 beers per day Family history: What? CAD. Who? Father-MI age 59. Demographics: Marital status: Married, Spouse name: Alicia Garcia, 59 y.o. Number of children: Daughter and two grandchildren live in the home Years education: AA degree Language: English, Spanish Occupation: IT network specialist Hours of work: 40/wk Household members: 5 Ethnicity: Mexican American Religious affiliation: Catholic MD Progress Note: General: Well-developed, overweight male in acute distress from chest pain. HEENT: Head: normocephalic and atraumatic Eyes: EOMI, fundoscopic exam WNL. No evidence of atherosclerosis, diabetic retinopathy, or early hypertensive changes. Mouth: oral mucosa pink, dentition in good repair Throat: pharynx pink without exudates Neck: soft, supple, no palpable masses. No lymphadenopathy. Cardiac: Isolated posterior MI with ST depression in V2-3. No murmurs, clicks, or rubs. Pulmonary/Chest: Lungs are clear to auscultation bilaterally. Abdominal: Abdomen soft, nontender, with normoactive bowel sounds in all four quadrants. No masses, no organomegaly. No guarding, rebound, or CVA tenderness. RLQ scar and midline suprapubic scar. A

Phlebotomy Essentials

6th Edition

ISBN:9781451194524

Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Chapter1: Phlebotomy: Past And Present And The Healthcare Setting

Section: Chapter Questions

Problem 1SRQ

See similar textbooks

Related questions

Question

Overall interpretation on Mr. Garcias medical chart. Please include food history (what’s good and bad) and his overall health.

Transcribed Image Text:Nutrition: Diet order: no added salt/low saturated fat; low cholesterol History: Appetite good. He and his wife have been trying to change some things in his diet. Wife indicates that she has been using "corn oil" instead of butter and has tried not to fry foods as often. Typical dietary intake: Breakfast: Coffee with milk and sugar Midmorning snack: Egg and cheese on English muffin from work cafeteria; 8 oz. orange juice, 2-3 c coffee with milk and sugar Lunch: Dinner: Snack: Leftovers from home; if eats in cafeteria: soup, salad, or sandwich. Had tomato soup and grilled cheese yesterday. Rice-1 c; black beans-1 c; roast pork with tomato and peppers- approx. 6 oz; cornbread-2 squares, each 2" wide Typically has chips or popcorn and 1-2 beers Food allergies/intolerances/aversions: None Previous nutrition therapy? No Food purchase/preparation: Spouse Vit/min intake: None Garcia, Jose, male, 01 y.o. Allergies: NKA Pt. Location: RM 704 Code: FULL Physician: RJ Warren Isolation: None Admit Date: 12/1 Allergies: NKA Pt. Location: RM 704 Code: FULL Physician: RJ Warren Isolation: None Admit Date: 12/1 Extremities: Normal range of motion in all four extremities. No cyanosis or clubbing or peripheral edema. Neurological: Conscious, alert, and oriented. Cranial nerves II through XII are intact grossly and symmetrically. No focal neurologic deficit. Skin: Skin is warm and dry. Mild diaphoresis. No rashes or ulcerations noted. Vital Signs: Temp: 98.6°F Orders: BP: 140/99 Pulse: 94 Height: 5'9' Resp rate: 23 Weight: 215 lbs ED: Oxygen 2 liters per NC to maintain O₂ SAT >95%; nitroglycerin 0.4 mg sublingual; aspirin 81 mg x 4 (324 mg total), to be chewed Heparin 70 units/kg bolus IVP (max dose 7500 units) Clopidogrel 600 mg oral Admission to CCU: Early risk stratification: high risk Activity: bed rest Cardiac monitor Vital signs q4h x 24 hours then q8h Diet: no added salt/low saturated fat; low cholesterol Call house officer for T>101, SBP >190 mm Hg or SBP <90 mm Hg, HR >120 bpm or HR <50 bpm, RR >30 or RR <10 Guaiac ALL stools while on heparin, LMWH, Ilb/illa inhibitor O₂: NC continue 2 L/min Please call house officer for O₂ SAT <90% Order for respiratory care O₂ SAT check q8h EKG and repeat for recurrent chest pain Troponin T/Troponin I: now and every 6 hrs x 8 times CK-MB: now and every 6 hrs x 8 times CBC, lipid profile, PTT, Chemistry (7) panel in AM-fasting Atenolol 75 mg/d Nitroglycerin 1/150 (0.4 mg) 1 TAB SL q 5 min x 3 prn chest pain; hold if: SBP <100 mm Hg PRN: Docusate sodium 100 mg po twice daily; aluminum-magnesium hydroxide 15 mL every 6 h for indigestion; oxazepam 15-30 mg po every hs prn insomnia; acetaminophen 650 mg po every 4 h for headache; magnesium hydroxide 30 mL po daily for constipation; magnesium sulfate sliding scale IV qd; call house officer if serum Mg <1.2 Hold order for creatinine >1.9 If serum Mg <1.4, give 5 g MgSO, IV; if serum Mg <1.6, give 4 g MgSO, IV; if serum Mg <1.8, give 3 g MgSO, IV; if serum Mg <2.0, give 2 g MgSO IV Patient Summary: José Garcia is a 61-year-old male admitted through the emer gency department with diagnosis of STEMI and transferred directly to Cath lab; s/p emergency coronary angiography with angioplasty of the infarct-related artery. History: Onset of disease: 61-y.o. male who noted the sudden onset of severe precor- dial pain on the way home from work. The pain is described as pressure-like pain radiating to the jaw and left arm. The patient has noted an episode of emesis and nausea. He denies palpitations or syncope. He denies prior history of pain. He admits to smoking cigarettes (1 pack/day for 40 years). He denies hypertension, diabetes, or high cholesterol. He denies SOB. Medical history: Not significant before this admission Surgical history: Surgery; cholecystectomy 10 years ago, appendectomy 30 years ago Medications at home: None Allergies: Sulfa drugs Tobacco use: 40-year history, 1 pack/day Alcohol use: 1-2 beers per day Family history: What? CAD. Who? Father-MI age 59. Demographics: Marital status: Married, Spouse name: Alicia Garcia, 59 y.o. Number of children: Daughter and two grandchildren live in the home Years education: AA degree Language: English, Spanish Occupation: IT network specialist Hours of work: 40/wk Household members: 5 Ethnicity: Mexican American Religious affiliation: Catholic MD Progress Note: General: Well-developed, overweight male in acute distress from chest pain. HEENT: Head: normocephalic and atraumatic Eyes: EOMI, fundoscopic exam WNL. No evidence of atherosclerosis, diabetic retinopathy, or early hypertensive changes. Mouth: oral mucosa pink, dentition in good repair Throat: pharynx pink without exudates Neck: soft, supple, no palpable masses. No lymphadenopathy. Cardiac: Isolated posterior MI with ST depression in V2-3. No murmurs, clicks, or rubs. Pulmonary/Chest: Lungs are clear to auscultation bilaterally. Abdominal: Abdomen soft, nontender, with normoactive bowel sounds in all four quadrants. No masses, no organomegaly. No guarding, rebound, or CVA tenderness. RLQ scar and midline suprapubic scar. A

Expert Solution

Step by step

Solved in 2 steps

SEE SOLUTION Check out a sample Q&A here