"I'm not diggin' that idea"

Week 2: 70 yo female

Med Dx: chest pain

PMHx: CHF (chronic heart failure), CKD (chronic kidney disease), HTN, DM Type II,  Hyperlipidemia, LBBB, Hyponatremia, chronic epigastric abd pain, anemia, atherosclerosis, allergic rhinitis

Isolation: standard precautions

This lady was admitted for chest pain, but as you can see, she has a host of other problems as well. The two main problems for her this week were her epigastric pain and CKD. Though she came in /c chest pain, that must have resolved pretty quickly b/c every time I did a pain assessment she said her only pain was the abd pain. (Btw, chronic epigastric abd pain is like a burning feeling in your gut d/t over production of acid. Protonix is a good med for reducing this excess acid.) Here's my SOAPE note for her abd pain:

S - pt c/o burning abd pain x1 week. pt states: "it burns, especially after I eat".

O - pt frequently mentions abd pain. pt no grimacing or showing other signs of discomfort.

A - abd soft, not distended. BT audible.

P - admin Protonix (40mg - schedule 0900 med). re-assess pain in 30-60mins /p admin.

E - Gave Protonix (40mg) @ 1000. 1045: following med admin & breakfast, pt reports burning pain decreased. 1230: reassess pt's pain, and pt reports not pain.

Problem Solved. :) The Protonix seemed to help and she really wanted to go home, but really, she also needed kidney dialysis (d/t the CKD). She really wasn't diggin' this idea, although she already has the fistula for it. (Fistula: this one was in her L arm at the elbow, near the area where you would have blood drawn. To make it, the surgeon connects an artery to a vein. The blood moves very turbulently through it, called "bruit", pronounced broo-ee, which you can feel, and hear (with the stethoscope). Anyhow, she "won" this battle and went home saying she would think more about dialysis.