Narrative – Cardiology

For this assignment you must write a narrative, just as you would on a PCR.

Scenario:

You and your partner are enjoying the rare treat of a quiet Sunday shift. You are watching television, and your partner is studying for final exams. You are about to drift off when the pager disrupts the tranquility. You are dispatched to the medical school library for an unknown medical emergency. On arrival you and your partner are led to the third floor stacks where you find a 22-year-old man complaining of palpitations.

Patient is a young well nourished man; appears anxious and nervous.  Oriented to person, place, and day.  Airway is open, breathing is normal rate and depth.  Radial pulse is strong and rapid with pink, warm, diaphoretic skin.

You ask your partner to obtain an initial set of vital signs while you begin your patient assessment. When asked about the palpitations, the patient tells you that they began about 45 minutes ago while he was studying for finals. He is a first-year medical student and needs to do well on finals to avoid being placed on academic probation. He admits to being awake for the past 36 hours with the help of “Monster” energy drinks and caffeine pills. His last solid oral intake was pizza last night around 11:00 PM. He denies any medical history or allergies and emphatically denies the use of any drugs other than the caffeine pills.

Patients pulse is strong and regular at 210.  BP 112/74.  RR 20, non-labored.  SaO2 95% on room air.

Your partner has applied the cardiac monitor and is giving oxygen at 4 L/min via nasal cannula. The cardiac monitor displays a narrow complex tachycardia at a rate of 212 beats/min.

While looking for a site for an intravenous (IV) line, you ask the patient to bear down hard as if he were having a bowel movement. There is no change in his rate and rhythm. You insert an 18-gauge IV catheter in his right forearm and then you rapidly administer 6 mg of adenosine, followed by a 20-mL fluid bolus. The monitor shows a transient decrease in the HR to 165 beats/min, which quickly picks back up to a rate of 206 beats/min. The patient tells you that he experienced a strange sensation in his chest when you gave him the medication and asks what you gave him.

The patient remains pink, warm, and diaphoretic.  Pulse is strong at 206.  ECG shows SVT.  BP 110/78.  RR 20 non-labored, SaO2 99% on 4L/m via NC.  Pupils equal and reactive.

Since the initial dose of adenosine caused a transient drop in the HR, you decide to administer 12 mg of adenosine. This time, you let the patient know that you will be administering the medication, and then give it followed by a 20-mL flush. The monitor shows a 3-second period of asystole followed by a gradual increase in the HR to approximately 210 beats/min. In 2 minutes, you administer another 12 mg of adenosine, the third and final dose, with similar results.

Patient’s vitals signs and appearance remain unchanged.

The adenosine did not work, but your patient continues to be in hemodynamically stable condition, which gives you the opportunity to continue treating him pharmacologically. In accordance with department protocols, you reach into the drug box and grab a prefilled syringe of diltiazem. Before administering the diltiazem, you recheck the protocol book and confirm the dose as 25 mg by IV push. As you administer the diltiazem, you realize that at any time the patient’s condition can become unstable, and synchronized cardioversion might become necessary.  After about a minute, you note that the HR on the cardiac monitor begins to steadily decrease, finally stabilizing at 104 beats/min. You contact the receiving emergency department, give your report, and receive no further orders.

Patient is now pink, warm, dry.  Pulse is now 104.  ECG shows normal sinus rhythm.  BP 124/76.  RR 18, non-labored.  SaO2 99% at 4L/m via NC.

Write your narrative to appropriately describe the treatment and care of this patient using the CHART or SOAP style of narrative.

ANSWER

Subjective

On a quiet Sunday shift, my partner and I were dispatched to the medical school library for an unknown medical emergency. Upon arrival, we encountered a 22-year-old, well-nourished male who presented with palpitations. The patient, a first-year medical student under stress due to upcoming finals, reported experiencing palpitations for the past 45 minutes. He admitted to staying awake for the past 36 hours using caffeine pills and energy drinks. He denied any medical history, allergies, or drug use other than caffeine pills.

History

The patient appeared anxious and nervous, with a strong and rapid radial pulse of 210 beats/min. His skin was diaphoretic and warm, while his blood pressure measured 112/74 mmHg. His respiratory rate was 20 breaths/min, and oxygen saturation on room air was 95%. The patient had not eaten since last night’s pizza at 11:00 PM.

Assessment

My partner applied a cardiac monitor and administered oxygen at 4 L/min via nasal cannula. The monitor revealed a narrow complex tachycardia at a rate of 212 beats/min. In an attempt to convert the rhythm, I inserted an 18-gauge IV catheter in the patient’s right forearm and administered 6 mg of adenosine, accompanied by a 20-mL fluid bolus. The patient experienced a transient decrease in heart rate to 165 beats/min, which quickly rose back to 206 beats/min. The ECG displayed supraventricular tachycardia (SVT), and the patient reported an unusual chest sensation from the medication.

Response to Treatment

Despite the initial adenosine administration, the patient’s condition remained stable. Noting this, I decided to administer 12 mg of adenosine, followed by a 20-mL flush. The monitor showed a brief period of asystole followed by a gradual increase in heart rate to approximately 210 beats/min. A subsequent 12 mg of adenosine yielded similar results.

Continued Treatment

The patient remained hemodynamically stable, allowing for further pharmacological treatment. I retrieved a prefilled syringe of diltiazem, confirming the dose as 25 mg IV push in accordance with department protocols. As I administered the diltiazem, I recognized the potential need for synchronized cardioversion should the patient’s condition deteriorate. After about a minute, the cardiac monitor displayed a steady decrease in heart rate, stabilizing at 104 beats/min. I contacted the receiving emergency department to provide a report and received no additional orders.

Conclusion

The patient’s condition improved with a decreased heart rate of 104 beats/min, reflecting normal sinus rhythm. His vital signs remained stable, and he appeared pink, warm, dry, and oriented. Blood pressure measured 124/76 mmHg, respiratory rate was 18 breaths/min, and oxygen saturation on 4 L/min via nasal cannula was 99%. The successful treatment and stabilization of the patient’s heart rate marked the completion of this care episode.

Throughout the patient’s treatment, the CHART-style narrative effectively documented the progression of care, from initial assessment and interventions to response and outcomes. The timely administration of medications, adherence to protocols, and communication with the receiving emergency department were integral in achieving a positive outcome for the patient.