Georgia Mathis | 48 years old
Chief Complaint: Georgia Mathis presents with severe retrosternal pain and difficulty swallowing following a recent episode of forceful vomiting.
Medical History:
Hypertension
Type 2 Diabetes Mellitus
GERD (Gastroesophageal Reflux Disease)
No known allergies
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Nurse's Note:
Patient reports excruciating retrosternal pain that began after forceful vomiting last night. Complains of difficulty swallowing and severe chest pain. Noted to be anxious and diaphoretic.
Vital Signs:
Blood pressure: 110/70 mmHg
Heart rate: 122 bpm
Respiratory rate: 24 breaths/min
Temperature: 101.2°F (38.4°C)
SpO2: 94% on room air
Provider's Orders:
Initiate NPO status immediately.
Administer IV fluids with normal saline at 125 mL/hr.
Start broad-spectrum antibiotics: Piperacillin-tazobactam (Zosyn) 3.375 g IV every 6 hours.
Obtain a chest X-ray, esophagram, and chest CT scan.
Consult thoracic surgery for evaluation and possible intervention.
Administer IV morphine 2 mg for pain once
Transfer patient to the ICU for close monitoring.
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Follow Up Questions:
Question 1: Why was it necessary to keep Georgia NPO immediately upon her arrival?
Question 2: What is the purpose of administering broad-spectrum antibiotics to Georgia?
Question 3: Why is a repeat esophagram ordered on postoperative day 7?
Question 4: What are the signs of mediastinal sepsis, and why is this condition critical?
Question 5: Why was a Jejunostomy tube needed?
Answers to Questions Below
Answers
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