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Myocardial Inattention Assessment

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Week Five Journal
M. B. was a sixty-five-year-old Caucasian female who had a significant history of diabetes, hypertension, and obesity. Her medication profile consisted the following: Norvasc 5 mg QD, Prinivil 10 mg QD, Coreg 6.25 mg BID, Metformin 100 mg BID, Lantus 10 units HS, ASA 81 mg QD, Lipitor 10 mg QD, and a multivitamin daily. She was positive for coronary artery disease, myocardial infarction, diabetes, and hypertension. Her family history was significant for coronary artery disease. Her father died at the age of fifty from a massive myocardial infarction. She lived a sedentary lifestyle without exercise. Her hobbies consisted of knitting. She continued to independently complete both her daily activities and instrumental activities …show more content…
She was unable to state the day or place. She mumbled and appeared to be preoccupied. I completed the confusion assessment method (CAM) test. She was CAM positive for delirium. She had features of acute fluctuation of mental status, inattention, and changes in baseline mental status. The inattention assessment was completed by performing the SAVEAHAART test. She was unable to squeeze my hand as requested. The lungs were clear in all fields. S1S2 were auscultated without a murmur. Negative peripheral edema/jugular venous distention was noted. We began to look for sources of infection. She was not febrile and was without complaints of pain, cough, or urinary frequency. A complete blood count, urinalysis, electrolytes, CRP, and urinalysis was ordered. These results were to be called to Dr. …show more content…
Education included information about acute delirium, causes, and treatment options. Moreover, potential complications were reviewed including sepsis and further compromise.
Outcome: The treatment plan was effective. The next week her mental status had improved. I was able to evaluate her the following week on my clinical day. Her delirium had resolved completely. She had asked Dr. Khan to ride in his Rolls Royce. She remembered he had this type of car. It was quite rewarding to see her turn around and witness such improvement in her condition. Upon reflection, we reviewed her reported urinalysis and complete blood count which validated that she had indeed had a urinary tract infection that led to her acute

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