UNIVERSITY HOSPITAL

Title
Family Name
Mr. BREATHER
Given Names
JUSTIN
Address
Street
18 MARSDEN STREET
Suburb
Postcode
CAMPERDOWN
2050

M.R.N.

123456

Age
Sex
55
M
Adm. date
15/08/2015

15/08/15

NURSING- Mr. Breather, a 55 y/o patient from Camperdown,

09:20

Sydney was brought in by ambulance due to chest pain and difficulty of

breathing early morning while sleeping. Wife called the

DOB
18/12/1960

triple zero for help. The patient has a history of smoking for
15 years, a coronary bypass surgery in 2009, asthma, hypertenSion , and insulin dependent diabetes mellitus. Medication
History includes Amlodipine as maintenance drug for HTN.
Vital signs are as follows: HR=100, BP= 180/110, RR=24, O2=
95% on 4LPM nasal prongs, T=37.0, BSL=10.2. ECG shows signs
Of ischemia with T-wave inversion on the reading. Plan includes
Administration of medications for chest pain and HTN as
Ordered by the doctor. Continue cardiac monitoring and do
ECG reassessment. Schedule the patient for 2D echo.
(F.LLANTO, RN)