Ocampo, Danilo

MR #5656954

Physician Assessment/Notes
Time: 0930
HPI
Patient reports shortness of breath and angina off and on for few weeks. Increased lower extremity edema reported for few weeks, also
noted on arrival. Has not been taking medications as prescribed for one week since wifes illness. Pt. reports increasing fatigue and
new onset chest pain, stated 10/10 on pain scale, with cough productive of pink, frothy sputum.
Pt. has hx significant for hypertension, MI, angina, and class 2 heart failure.
Examination Findings
Neuro: Anxious but oriented.
ENT: Normocephalic, PERRLA- 3 mm.
CV: HRRR; no murmurs; pulses +1 thready; cap refill 3 seconds.
Resp: Shallow, rapid respirations with bilateral crackles noted.
GU: Negative.
Mus/Skel: Symmetrical and equal.
Impression: Acute MI, worsening heart failure.

Physician Orders:
Time
Ordered
0940

0955
1010

1015
1025

1030

1040
1045

Order
Repeat Stat ECG, cardiology
consult. Morphine 2-4 mg Q
1hr PRN chest pain.
Nitroglycerine 1 tab SL Q5
min PRN chest pain- 3 tabs
total. 0.9%NaCL@50 mL/hr
IV.
Ativan 1mg IVP now for
anxiety.
Repeate cardiac enzymes
Q4hr x 24 hr. starting at
1200.
Morphine 2mg IVP x 1 now
Dobutamine IV continuously
at 5 mcg/kg/min, titrate to
MAP of 65.
Ativan 2 mg IVP, Fentanyl
25 mcg IVP, Vecuronium
10 mg IVP, and Etomidate
20 mg IVP-for intubation.
Stat chest xray for tube
placement, stat ABG.
Vent settings: SIMV 16, 1.0,
8/12.
See code sheet.

RN
Initals
0945SK

1000 SK

1015 SK
1030 SK

Physician Notes
0950- ECG shows significant ST elevation noted in V1 to V4. Lab results
returned as follows: CBC- WNL, CH12- K+- 3.6, Na- 136, CO2- 22,
Chloride- 100, BUN- 12, Creatinine- 0.8. ABG: pH- 7.28, CO2- 55, PaO278, Bicarb- 24. UA- WNL, Digoxin level-0.1 ng/ml. Cardiac enzumes:
CK- 336 U/L, CK-MB- 10.8IU/L, Troponin- 1.0 ng/ml.
1010- Cardiology consult arrives. Dr. Cox states pt. is mostly likely in heart
failure due to non-adherence to medication regimen. Dobutamine gtt.
recommended.
1035- Patient having increased shortness of breath. Intubated with 7.0 ETT,
secured at 22 cm. Vent settings- SIMV rate 16, FiO2 100%, PEEP 8,
Pressure Support 12.
1045- Patient into v-fib. Resuscitation efforts started. Please see code sheet.

1035 SK

1040 JM

Consultation: Cardiolgy
Diagnosis: Acute MI progressing to cardiogenic shock
Disposition: Deceased
Physician Signature: James
RN signature:

Arrival Time: 1010

Gordon, MD

Sjori Kauffman, RN

RT signature: Jenna

Melendrez, RRT

Ocampo, Danilo

MR #5656954

Emergency Department Nursing Flow Sheet

Time

BP

HR

RR

O2 Sat

Pain

0945

106/66
MAP
(73)
100/64
(70)

104

26

36.9C

98% 0.50
NRB

10/10
VAS

Morphine 4 mg IV for chest pain. ECG done.

Pt. c/o SOB, appears anxious, diaphoretic.

SK

99

28

99% 1.0
NRB

9/10
VAS

SK

1000

95/61
(69)

87

28

93% 1.0
NRB

7/10
VAS

1015

94/60
(64)

115

33

90% 1.0
NRB

10/10
VAS

1030

88/54
(59)

118

41

88% 1.0
NRB

10/10
VAS

1035

85/53
(57)

117

40

85%1.0
NRB

Unable
to assess.

1040

86/52
(57)

110

16

90% 1.0
vent

1045

0/0

16

0/10
Noncomm.
adult
1/10
Nomcomm.
adult

Pt. states pain slightly improved post Morphine. SOB

unchanged Pt. remains anxious. Ativan 1 mg IVP
given for anxiety. Nitroglecering 1 tab SL given for
chest pain.
Pt. states slight improvement, appears more
comfortable at this time, now slightly confusedreorients easily. Chest pain continues, crushing per
pt. when asked.
Pt. states pain horrible when asked. Pt becoming
combative with increasing confusion. Morphine 2 mg
IVP given per Dr. Gordon. Pt. having frequent,
multifocal PVCs.
Dobutamine gtt started at 5 mcg/kg/min. per Dr. Cox,
cardiology. Pt having obvious respiratory distress,
states yes when asked if he wants a breathing tube
placed.
Pt. intubated by Dr. Gordon on 1st attempt. Ativan 2 mg
IVP, Fentanyl 25 mcg IVP, Vecuronium 10mg IVP,
and etomidate 20 mg IVP prior to intubation.
Pt. on vent per Jenna, RRT. See respiratory flowsheet.
Pt. remains unresponsive, dobutamine gtt increased to
8 mcg/kg/min. to increase MAP to 65. Chest xray
done, labs sent as ordered.
Pt. into V-fib, 0 pulses. Dr. Gordon at bedside. See
code sheet.

0955

37.6C

37.8C

Fluid Intake
Time
Type
initated
0945
1030

90% 1.0
vent

Amount
infused

0.9% NaC1 @ 50 mL/hr 30 mL

Dobutamine gtt
10 mL
@ 5 mch/kg/min

TOTAL

Discharge Instructions: N/A

Assessment/Response

Fluid Output
Time
Type

Amount

30 mL
40 mL

0945
1030

450 mL
200 mL

40 mL

TOTAL

Running
Total

Urine
Urine

Disposition: Deceased

Time Discharged from ED: N/A

RN Signature:

Sjori Kauffman, RN

Tech Signature: Tom Parker

Initials

SK

SK

SK

SK
SK

SK

Running
Total

450 mL
650 mL

750 cc

Ocampo, Danilo

MR #5656954

Neighborhood Hospital
Cardiopulmonary Resuscitation Record

Date: Thrusday Location: ED- Cardiac room Service: Emergency Medicine

Witnessed arrest: X Unwitnessed arrest:___ Respiratory arrest:___ Cardiac arrest: X
Code Chronology
Time Code Event Recognized: 1045
Time CPR started: 1045
Code Team Called? No
Time Code Team Called: N/A
Time Code Team Arrived: N/A

AED Time: 1048

Code Status: Full

Number of Shocks: 4

Presenting Hx R/T Code: chest pain, shortness of breath, cough productive of pink, frothy sputum. Hx. of heart failure, hypertension, MI.
On cardiac monitor prior to arrest? Yes
Intubated prior? Yes
Admitting Dx: acute MI, heart failure
Glasgow Coma Scale:
Pupil Guage: 3 4 5 6 7 8 (mm)___ Pupils: Equal reac Fixed/No reac Unequal__________
Respiratory Assssment/Interventions:
Intubated during code? No
Intubated by: Dr. Gordon
Time of Intubation: 1035
Tube placement: 22 cm at teeth
Spontaneous ventilation: No
Size of ETT: 7.0
Oral X Nasal___
Bilateral breath sounds: Yes
Airway ETT X LMA___
Number of intubation attempts: 1- prior to code
Ambu bag w/ 100% O2? Yes Comments:___________________________________________________________________________
Prior IV Status:
Initiated IV Status:
External Pacemaker Used: No
#16G IV catheter, (L) #18G IV catheter.
None initiated during code.
Time

Rhythm

1045
1046
1047

V-fib
V-fib
V-fib

200
200
N/A

1048
1050

V-fib
V-fib

200
N/A

1052

Asystole

N/A

1055

Asystole

N/A

1057

Asystole

N/A

ABGs:
Time
1048

Joules

Site
R radial

Med/Dose/
Route
None
None
Epinephrine
1mg IVP
None
Amioarone
300mg IVP
Epinephrine
1mg IVP
Epinephrine
1mg IVP
N/A

FiO2

pH

Response

Pulse

BP

O2

CPR

BVM

No change
No change
No change

0
0
0

0/0
0/0
0/0

99
100
100

Yes
Yes
Yes

No change
No change

0
0

0/0
0/0

100
100

No change

0/0

No change

PaCO2

100%

6.98

Comments

Yes
Yes
Yes

Fluid
Vol.
100 mL
0
0

Yes
Yes

Yes
Yes

0
100 mL

ABG sent
Calling
family

100

Yes

Yes

0/0

100

Yes

Yes

0/0

100

Yes

Yes

Pa02
61

HC03

%Sat

82

22

Other Lab
100%

Post Arrest Status

Survived: No
Family Notified? Yes
Vital Signs: N/A
Rhythm: N/A
LOC:N/A
Transferred to: N/A Time: N/A

Expired: Yes Time: 1057 Pronounced by: Dr. Gordon

OMI Notified: Yes
Time: 1110 ___N/A
Family Notified? Yes Name: Kristina- niece By: Dr. Gordon
Autopsy Requested? Yes Requested By: Kristina- niece
Donor Services Notified? Yes Time: 1115
By: Dr. Gordon

Print Name
Recorder:
Meds By:

Jordan Shirk, RN
Sjori Kauffman, RN

RN Leader:
MD Leader:

Bryce DiLuzio, RN
James Gordon, MD

Resp. Therapist:

Jenna Melendrez, RRT

Code
Called

Signature
Jordan Shirk, RN

Sjori Kauffman, RN
Bryce DiLuzio, RN

James Gordon, MD
Jenna Melendrez, RRT

N/A