Could it be a heart attack or Pneumonia?

[Isis Phoenix]

Patient M. Dean is a 53 years old male with a DX of CVA with Left sided weakness who came to the ER to be evaluated for chest pain, and respiratory discomfort which started two days ago, but suddenly escalated .... RR. 9 irregular and guarded, HR. 130 and regular, BP. 180/90, Oral Temp. 101 degrees (F) He also denies injury related to accident, however he thinks that he may be having a heart attack. How do we proceed to evaluate this patient, and what possible diagnosis medical,as well as nursing diagnosis would be made?

[BostonFNP, APRN]

Based on the little clinical information and history, medically I would be sending the pt for a stat n/c CT head and a d-dimer. But it's tough without any assessment info or a 12-lead.

[Esme12, ASN, BSN, RN]

How about an EKG?

I said EKG...LOL

Stat labs (Cap glucose, CBC, coag, enzymes, chem 18, BL culture, Stat PORT CXR, Stat EKG, Stat CT for the ED we do UDA)

[Dranger]

Medical Management:

RE: Dranger :For lowering the BP and improving profusion Nitro drip can be titrated until a satisfactory BP is achieved, or once the patient is intubated Morphine drip could be considered, although he may need more medication for hemodynamic support.

NB. TX will be made according to the medical diagnosis.

Nursing Management:Implementing orders, titrating medication, measuring vitals, obtaining EKG's, assessing,evaluating patient response, reporting to medical/nursing teams, and writing nursing notes etc.

“I do not have all the answers but,together we can find them.”

(M Ecallawh)

His BP is fine currently for post CVA perfusion. That's why I asked in a previous post how long ago was the CVA? Without that knowledge how would I know? You were saying he was have some chest pain/discomfort and I would not use nitro for that until a valid dx was laid out.