Cardiac System Case Study

Sometimes the order of your assessment and data collection changes depending on the severity of presenting symptoms…like in an Emergency Situation.  

George Wesley, a 58-year-old accountant presented to the emergency department with complaints of chest pain.  He is diaphoretic and anxious, and is clenching his fist against the center of his chest. The patient and his wife are admitted to the examination room. 

You perform the initial assessment, focused history and interview while your partner RN completed the physical assessment and prepares to follow the ED protocol.(pulse oximeter, prepares to administer oxygen, IV lines started). Note the vital signs in the chart below.

Chief complaint: "My chest feels tight and I feel really weak."
Airway and breathing: Airway is patent; respirations are slightly increased and unlabored.
Oxygen saturation: 97% (on room air).
patient and wife
Past history:  Hypertension controlled with medication.  No known history of heart disease or chest pain or diabetes.  No known allergies.