Order Description
Case
You are tasked to a 53 yo male with increasing shortness of breath
Assessment
Patient is pale cool, clammy, looking fatigued and unwell, Dizzy
RR 28, SpO2 95%, BP 180/110, HR 75, Cap refill >3 secs,
ECG
I will upload the ECG.
Eyes, Pale conjunctiva, pupils EARRL size 2 sluggish, peri-orbital oedema
Lungs – bibasilar crepitations,
Normal heart sounds
Abdo distended, extremities pitting oedema to the sacrum,
PMHx
Nil allergies
End stage renal disease on haemodialysis x 3/week, HT, Diabetes, Hyperlipidaemia, Coronary artery disease, asthma
Medications – lisonopril, glargine, novorapid (Sliding scale), aspirin, simvastatin, salbutamol, breo, hydrocortisone cream,
FHx – HT, diabetes, CAD
Social history – smoker, occasional EToH, no recreational drugs
What do you know about the patient? What is the key information? What do you still need to find out?
Outline 3 provisional diagnoses.
Discuss your final diagnosis and the pathophysiology behind the diagnosis.
Discuss the implications for paramedic practice.
Reference List
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