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SITUATION

Patient: Carlos Garcia, age: 45, Obese male of Mexican descent, History of HTN, pneumonia, pancreatitis

Chief Complaint: Mr. Garcia is admitted to the medical unit for exacerbation of pancreatitis. He is
scheduled for removal of his gallbladder tomorrow.

History of present illness: Mr. Garcia has been experiencing nausea and vomiting for three days and
intermittently felt lightheaded and sweaty before being seen in the emergency department for intensifying
abdominal pain. At home he takes Lisinopril for hypertension and reports taking some ibuprofen for his
abdominal pain. Additionally, he reports “chewing Tums like candy” throughout the day. Carlos has been
NPO for 1 ½ days except for occasionally drinking water because he reports “I thought it might help my
pain.”

Social history: Carlos is married to his wife Silvia. They have been married for 18 years and have two
children – Michael 16 and Cathryn 13. He works as a financial executive at a local corporation, typically
working 60-70 hours a week. He describes himself as Catholic and reports attending church every Sunday.

Current medications in the hospital: Lisinopril 20 mg po daily, Zofran 4 mg IVP every 4 hours prn for
nausea, hydromorphone (Dilaudid) 0.5-1 mg prn for pain, Meds per standing orders (if you need some
based on assessment/screening…)

 

ASSESSMENT

Upon your morning assessment, you notice the following:

VS – BP: 148/90; HR: 110; RR: 18; T: 98.4; O2 sats: 96% on RA; rates
pain 3/10 (has just had an IV analgesic)

Carlos complains of nausea

You notice that as Carlos reaches for his glasses, his hands are trembling.
He just returned from the bathroom and is sweating.

 

Carlos Garcia

Write out two outcomes for Carlos at this point.  

 

2. Interventions: List interventions in priority of action – Please include what you would assess/monitor, medications you would give, etc.

 

3. What will you say to Carlos and his family?

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