0630 handoff. Mr. T, 64, was admitted two days ago with atrial fibrillation with rapid ventricular response and NSTEMI and had PCI with a drug-eluting stent yesterday. He receives aspirin, ticagrelor, a weight-based heparin infusion, and a morphine PCA (1 mg demand dose, 8-minute lockout, 20 mg four-hour limit, no continuous basal infusion, patient-only activation). Potassium chloride 40 mEq in 100 mL labeled CENTRAL LINE ONLY is running through a peripheral antecubital IV. At 0200 he was drowsy but conversant and rated pain 3 of 10. Now: temperature 36.9 C, heart rate 78 in sinus rhythm, respirations 10 and shallow, blood pressure 108/62 mm Hg, similar to overnight readings, and SpO2 92 percent on 2 L/min. Pain is 1 of 10. He arouses only to firm voice; pupils are 2 mm and reactive. His wife says she used the PCA while he slept, pressing the button because he looked uncomfortable. The PCA history shows 18 demands, 14 deliveries in four hours, within the programmed limit. His son relays that Mr. T complained of burning at the IV site for the past 30 minutes. An aPTT of 92 seconds at 0200 exceeded the 60 to 90 second target; the repeat is due at 0800, and there is no overt bleeding at any site.
0630交班紀錄。64歲的T先生兩天前因心房顫動伴快速心室反應和非ST段上升型心肌梗塞入院，昨天接受了PCI並置入藥物塗層支架。他正在接受阿斯匹靈、替格瑞洛、依體重計算的肝素輸注，以及嗎啡PCA（單次需求劑量1毫克，鎖定時間8分鐘，四小時限制20毫克，無連續基礎輸注，僅限病患啟動）。標示為「僅限中央靜脈」的40 mEq氯化鉀溶於100毫升溶液中，正透過周邊肘前靜脈輸注。0200時，他嗜睡但能對話，疼痛評分為3分（滿分10分）。現在：體溫36.9°C，心率78次，竇性心律，呼吸每分鐘10次且淺，血壓108/62 mm Hg，與夜間讀數相似，以及血氧飽和度92%（每分鐘2公升氧氣）。疼痛評分為1分（滿分10分）。他對強烈聲音才有反應；瞳孔2毫米，對光反應靈敏。他的太太說她在他睡覺時使用了PCA，因為他看起來不舒服而按壓了按鈕。PCA歷史紀錄顯示，四小時內有18次要求，14次給藥，在設定限制內。他的兒子轉述T先生抱怨靜脈注射部位灼熱已持續30分鐘。0200時的aPTT為92秒，超過了60至90秒的目標範圍；重複檢測預計在0800進行，且所有部位均無明顯出血。