| 1 |
Performed hand hygeine |
| 2 |
Introduced self to patient |
| 3 |
Assessed level of consciousness
(alertness/orientation: person, place, time, etc) |
| 4 |
Acquired History of Present Illness (asked
questions about chest pain - where, how long, how bad, etc?) |
| 5 |
Acquired Past Medical History (do you have
medical problems for which you see a doctor?) |
| 6 |
Acquired Past Surgical History (have you had
surgery? When?) |
| 7 |
Acquired Family Hx (does anyone in your family
have heart disease; other health problems?) |
| 8 |
Acquired Social Hx (alcohol, tobacco, illicit
drugs) |
| 9 |
Asked about Allergies (allergies to foods or
medications?) |
| 10 |
Asked about Current Medications |
| 11 |
Asked about last dose of Sildenafil
(Viagra) |
|
Physical Exam (including obtaining
vital signs) |
| 12 |
Applied bedside ECG |
| 13 |
Confirmed patent IV in place or requested IV
placement (is there a working IV?) |
| 14 |
Placed Pulse Oximeter |
| 15 |
Applied BP cuff |
| 16 |
Checked temperature |
| 17 |
Checked BP in both arms |
| 18 |
Auscultated heart (MUST auscultate in 4 points
on chest and over carotids) |
| 19 |
Ausculated lungs (Credit for >3 lung
fields on EACH side) |
| 20 |
Auscultated abdomen (Credit for >2
areas of auscultation PLUS palpation and “does this
hurt?”/any pain?) |
| 21 |
Examined extremities (Credit for checking
pulses in both arms and checked for edema in legs) |
| 22 |
Examined patient's neck |
|
Differential Diagnosis |
| 23 |
Listed correct DDX (Acute Coronary (Acute MI,
Heart Attack, STEMI), Pulmonary Embolus (PE), Pericarditis, Esophageal
Rupture (Boerhaave's), Aortic Dissection, Pneumothorax
(PTX)) |
|
Labs and Tests |
| 24 |
Ordered 12-lead ECG |
| 25 |
Ordered Portable Chest x-ray |
| 26 |
Ordered correct labs (BMP, CBC, Cardiac
Enzymes, LFT's, Coags (PT, PTT, INR), d-dimer |
|
Diagnosis |
| 27 |
Correctly diagnosed “Anterior-Lateral
STEMI” (ST elevation MI) |
| 28 |
Correctly assessed CXR - no acute
cardiopulmonary problem/normal aorta/no air in mediatinum/no pericardial
effusion |
| 29 |
Correctly assessed labs [need to
mention elevated Troponin and Glc] |
|
Management |
| 30 |
Placed supplemental oxygen (NC if
SaO2>90%, FM if SaO2<90%; must titrate
for SaO2>94%) |
| 31 |
Ordered Immediate Cardiology Consult |
| 32 |
Requested/mentioned to activate cath lab |
| 33 |
Ordered Nitroglycerin (sublingual, paste, or
infusion) |
| 34 |
Ordered Aspirin 325mg - verbalized that
patient is to chew this |
| 35 |
Ordered heparin bolus and infusion (okay to
NOT know dose) |
| 36 |
Participant stated that it was safe to give
Heparin b/c CXR normal and BP equal in both arms |
| 37 |
Ordered Plavix (clopidigrel load) 300-600mg
PO |
| 38 |
Ordered Lipitor or Simvastatin 80 mg PO |
| 39 |
Ordered Lopressor (metoprolol) 5mg IV |
| 40 |
Ordered bolus 1L Normal Saline or Lactated
Ringer's |
| 41 |
Ordered Mucomyst 600mg PO to be given
immediately |
| 42 |
Requested monitor for transport to cath
lab |
