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    Task+2+ +Charles+Dothraki

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    Vin Meneses
    Charles Kane Dothraki, a 45-year-old man, presented to the emergency department with difficulty breathing for the second time. He has a history of tuberculosis since 2017 and was stabbed near the chest in 2018. On his first admission, he had a pericardial effusion drained but left against medical advice. He has now returned with worsening breathing difficulties and signs of cardiac tamponade. Emergency pericardiocentesis is planned and close monitoring will be needed due to the risk of complications.

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    Task+2+ +Charles+Dothraki

    Uploaded by

    Vin Meneses
    186 views2 pages
    Charles Kane Dothraki, a 45-year-old man, presented to the emergency department with difficulty breathing for the second time. He has a history of tuberculosis since 2017 and was stabbed near the chest in 2018. On his first admission, he had a pericardial effusion drained but left against medical advice. He has now returned with worsening breathing difficulties and signs of cardiac tamponade. Emergency pericardiocentesis is planned and close monitoring will be needed due to the risk of complications.

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    Charles Kane Dothraki, a 45-year-old man, presented to the emergency department with difficulty breathing for the second time. He has a history of tuberculosis since 2017 and was stabbed near the chest in 2018. On his first admission, he had a pericardial effusion drained but left against medical advice. He has now returned with worsening breathing difficulties and signs of cardiac tamponade. Emergency pericardiocentesis is planned and close monitoring will be needed due to the risk of complications.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    186 views2 pages

    Task+2+ +Charles+Dothraki

    Uploaded by

    Vin Meneses
    Charles Kane Dothraki, a 45-year-old man, presented to the emergency department with difficulty breathing for the second time. He has a history of tuberculosis since 2017 and was stabbed near the chest in 2018. On his first admission, he had a pericardial effusion drained but left against medical advice. He has now returned with worsening breathing difficulties and signs of cardiac tamponade. Emergency pericardiocentesis is planned and close monitoring will be needed due to the risk of complications.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    You are Alice Murphy, a qualified nursing sister working in the

    emergency department of Prince Charles General Hospital. Address


    Case Notes is 10 Downing Street, London, SW1A 2AA. Contact Ph. 400 3897
    7642. The patient had arrived from an ambulance for the 2nd time
    due to breathing difficulties.
    Patient details
    Name Charles Kane Dothraki
    Age 45 years old
    Date of Birth August 09, 1963
    Date of admission June 13, 2018
    Discharge Date June 16 2018
    • Father – suffered from Tuberculosis
    o Died last March
    • Mother – hypertensive
    o Currently on amlodipine 25mg mane
    Social History o BP: 160/95 mmHg
    • Living in a nuclear family type
    • Has tuberculosis since 2017
    • Has been stabbed near the chest area after a hold-up incident
    • Abnormal vital signs before discharge
    13th of June 2018
    • Had fluid accumulation in the pericardial sac
    • Was aspirated and resumed a normal cardiac rhythm
    • (Pericardiocentesis) aspiration done, but refused to be further
    treated in the hospital
    • Wanted to go home
    • Verbalized anxiety
    • In pain -- given pain killers for relief as needed
    • Abnormal ECG results
    • Abnormal heartbeat
    • Presented with difficulty of breathing until stable
    Medical history
    16th of June 2018
    • Signed a DAMA
    • Discharged with no known definitive progress
    • Accompanied by sister upon discharge
    • V/S: BP: 130/90
    • PR: 86
    • RR: 22
    25th of June 2018
    • Rushed into ER due to difficulty of breathing
    • RR: 30 shallow and grimacing
    • HR: 110
    • Could not speak
    • Hands held chest area
    • Muffled heart sounds on auscultation
    • Jugular vein distention
    • Pallor or cyanosis
    • Pulsus paradoxus
    • Restlessness
    • Chest X-ray showed slight cardiomegaly
    Diagnostic test results • Echocardiography recorded pericardial effusion with signs of
    right ventricular and atrial compression
    • For close monitoring of ECG changes, blood pressure, pulse
    rate, level of consciousness, and urine output to detect signs of
    decreased cardiac output
    • For emergency aspiration
    Plan • Explain the procedure to the client’s sister
    • Postoperatively monitor critical parameters, such as vital signs
    and ABG levels, and assess and breath sounds.
    • Give pain medication as needed
    • Be alert for complications, such as hemorrhage and arrhythmia

    Writing task #1
    Using the information in the case notes, write a letter to Dr. Alfredo Cordova -- Senior
    for Admission of the patient and emergency surgery.
    ■ Expand the relevant notes into complete sentences
    ■ Do not use note form
    In your answer ■ Use letter format
    ■ The body of the letter should be approximately 180 – 200
    words.

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