Situation
Dr. Jones, I am (Student’s Name) calling from the Cardiac Intensive Care Unit. I have a patient by the name Von who is in room 204. The 45-year old patient who tends to look calm but confused has a pulse rate of 110 beats per minute and blood pressure of 98/40. The patient also exhibits breathing challenges right from his 31 breaths in a minute. Since the temperature of the patient is at 35 degrees Celsius, I am concerned with the other readings.
Background
The patient’s mental status is well, only that he seems confused with the situation, which is the first cardiac complication in his life. Mr. Von may look calm but stressed, but this should not be a worry. The extremities of the patient are cold and dry, and this indicates his inability to supply more oxygen to the body parts. The patient is on digoxin 0.25mg; he takes it once every morning. Two days ago, the patient’s potassium in the body was 3.8. Von is undergoing bowel preparation because he is supposed to go for a colonoscopy in the afternoon. This decision came as a result of a test that found heme in Von’s stool.
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Assessment
The problem of this patient seems to be cardiac. I derived this conclusion from the results of the tests I conducted on the patient. It would be better if there were evaluation of atrial fibrillation because the situation keeps deteriorating. We need to take action before it is late because the cardiac system tends to keep being unstable.
Recommendation
I am requesting that you come to see the patient as soon as possible. The patient needs an electrocardiogram test in evaluating the electrical signals of the heart. This test will help in adjusting abnormal breathes per minute, blood pressure, and the heartbeats per minute. Please help us understand how often we need to communicate about the case and the vital signs.
