Situation
Kevin is a 19 year old male, admitted for caffeine intoxication.
Background
Yesterday, the patient presented with heart palpitations and light-headedness. Stressors from his college lifestyle are associated with an excessive consumption of energy drinks.
Assessment
Kevin is still reporting that his heart is racing, that he feels really dizzy, and like he can’t catch his breath. I’ve observed that he has persistent tremors too.
His most recent vitals are a pulse rate of 127 beats per minute, 19 breaths per minute, a blood pressure of 141 over 95, and a 98% pulse oximetry.
Recommendation
For Kevin’s next steps, I or the next shift’s nurse will need to confirm that he has a consultation scheduled with cardiology, as well as follow up on his toxicology panel.
CUS example
Dr Grace, I just saw Emmanuel coughing up blood. I’m concerned that this information was not included in his assessment, and may be necessary to get a full picture about his health.
I’m uncomfortable with the fact that his healthcare proxy Derek wasn’t an official translator – something about his symptoms could have got lost in translation.
I think it’s a safety issue to proceed with the chest infection diagnosis without Emmanuel using an official translator to describe his symptoms.
