Bulacan Medical Center

Department of Internal Medicine

City of Malolos, Bulacan
email add: bmc_med_dept@yahoo.com

CLINICAL PATHWAY FOR ACUTE CORONARY SYNDROME

INCLUSION • Age: >18 years old
CRITERIA • With symptoms of chest pain (whether typical or atypical in presentation)
• History of CAD, prior PCI and CABG
EXCLUSION • Other causes of chest pain (e.g., aortic dissection, pulmonary embolism)
CRITERIA • If patient was transferred from another hospital, proceed to ACS pathway

Last Name First Name Middle Extension WARD BED NO. HOSPITAL PHIC
(e.g. Jr/Sr) NO. NO.

Birthday: Age: Gender: Marital Status  S  W Nationality Religion

mm/dd/yyyy  M  M  A
_ _/_ _/_ _ _ _  F  Sep
Pathway Time:  AM Pathway Time:  AM Resident Physician in Charge:
Activated On: _ _:_ _  PM Activated Off: _ _:_ _  PM
_ _ / _ _ / 20_ _ _ _ / _ _ / 20_ _

DATE/
TIME CLINICAL NOTES PHYSICIAN’S ORDER VARIANC SIGNA-
C A R E D
E TURE
Day 1 Day 1
Subjective: • Admit to:
• ☐ ICU ☐ MMW ☐FMW
Co morbid Illness • Under the service of TEAM ___________
Controlled? • Please secure consent for Admission
• Please accomplish admitting history and PE
Diabetes Mellitus database as applicable
□yes □no • Refer to the following service(s):
☐ Cardiology
Active CA ☐ Pulmonology
□yes □no
☐ Nephrology
☐ Others: ______________________
Neuro Disease
MONITORING:
□yes □no
• Check and monitor Vital Signs every:
CAD ______hours
□yes □no • Urine Output every ____ hours
• Hook to Cardiac Monitor
• Watch out for _______
CHF
□yes □no ☐ Dyspnea
☐ Headache
Renal failure ☐ Chest pain
□yes □no ☐ Hypotension
DIAGNOSTICS (within 10-30 minutes):
COPD • 12-L ECG
□yes □no • Cardiac Panel
• Chest X-ray
Liver disease • CBC with platelet count
□yes □no • Creatinine

BMC IM 2021 | Clinical Pathways | ACS

 • Sodium
OBJECTIVE: • Potassium
Vital Signs: • Protime/ Partial thromboplastin time
HR: _____ bpm • Random blood sugar
BP: _____ mm Hg • SGPT
RR: _____ cpm • SGOT
Temp: _____ °C • Urinalysis
O2 sat: ____ %
(room air) OTHER DIAGNOSTIC TESTS:
• ABG
Admitting • 2D- Echo
Impression:
MEDICATIONS:
☐ Aspirin 80 mg tab, 4 tabs p.o. chew STAT
☐ Clopidogrel 75 mg/tab, 4 tabs p.o.chew STAT
☐ Ticagrelor 90 mg/tab, 2 tabs p.o.
☐Enoxaparin
☐ 0.4 cc SC BID
☐0.6 cc SC BID for 5 days
☐ Fondaparinux 2.5 mg SC for 5 days
☐ Isosorbide dinitrate 5mg/tab SL stat dose
☐ Nitrate patch 5 mg anterior chest wall
☐ Isosorbide Dinitrate drip at ____________
Nursing ☐ Morphine
Assessment: ☐2 mg IV
☐4 mg IV every __________
☐ OTHERS:
_______________________________

TREATMENT:
☐ Oxygen at _______Liters per minute via
nasal cannula to maintain >SPO2 93%
☐ Oxygen at _______ Liters per minute via face
mask to maintain >SPO2 93%
☐ Start IVF: __________________
To run for ______________ ml/hr

DIET AND NUTRITION:

☐ Nothing per Orem
☐ Soft diet
☐ Diet as tolerated

ACTIVITY:
• Complete bedrest without bathroom
privileges
• Limit visitors

OUTCOMES:
• No Dyspnea ☐ Yes ☐ No
• No Chestpain ☐ Yes ☐ No
• No hypotension ☐ Yes ☐ No
• Stable comorbids ☐ Yes ☐ No

BMC IM 2021 | Clinical Pathways | ACS

 DAY 2 DAY 2
SUBJECTIVE: □ Continue O2 supplement with
Symptoms □___ lpm via nasal cannula
□ chestpain □___ lpm via face mask
□ dyspnea □ Discontinue O2
□ headache □ Continue monitoring VS every ____ hours
BP ____ mmHg
OBJECTIVE: HR ____ beats/min
Vital Signs: RR ____ cycles/min
HR: _____ bpm O2 saturation: ____ %
BP: _____ mm Hg □ IV fluid to follow:
RR: _____ cpm ____ mL to run for____ mL/hr
Temp: _____ °C □ Shift to heplock
O2 sat: ____ % □ IV fluids to consume
(room air)
DIAGNOSTICS:
Normal? □ repeat CBC with platelet in AM
HEENT: □ repeat Chest Xray PA in AM
□yes □no □ repeat BUN ___ today ____in AM
Findings if not □ repeat Creatinine ____ today ____ in AM
Normal: □ repeat Na ____ today ____in AM
□ repeat K _____ today ____ in AM
________________ □ repeat Trop I
□ repeat 12L ECG
Chest/Lungs: □ others ___________________________
□yes □no
Findings if not MEDICATIONS:
Normal: □ Continue antiplatelets

________________ DIET:
CVS: □ Regular diet
□yes □no □ May have soft diet with aspiration precautions
Findings if not □ Maintain on NPO
Normal:
OUTCOMES:
________________ • No Dyspnea ☐ Yes ☐ No
Abdomen: • No Chestpain ☐ Yes ☐ No
□yes □no • No hypotension ☐ Yes ☐ No
Findings if not • Stable comorbids ☐ Yes ☐ No
Normal:

________________
Extremities:
□yes □no
Findings if not
Normal:

________________

Neuro:
□yes □no
Findings if not
Normal:

________________
Working
Impression:

BMC IM 2021 | Clinical Pathways | ACS

 DAY 3 DAY 3
SUBJECTIVE: □ Continue O2 supplement with
Symptoms □___ lpm via nasal cannula
□ chestpain □___ lpm via face mask
□ dyspnea □ Discontinue O2
□ headache □ Continue monitoring VS every ____ hours
BP ____ mmHg
OBJECTIVE: HR ____ beats/min
Vital Signs: RR ____ cycles/min
HR: _____ bpm O2 saturation: ____ %
BP: _____ mm Hg □ IV fluid to follow:
RR: _____ cpm ____ mL to run for____ mL/hr
Temp: _____ °C □ Shift to heplock
O2 sat: ____ % □ IV fluids to consume
(room air)
DIAGNOSTICS:
Normal? □ repeat CBC with platelet in AM
HEENT: □ repeat Chest Xray PA in AM
□yes □no □ repeat BUN ___ today ____in AM
Findings if not □ repeat Creatinine ____ today ____ in AM
Normal: □ repeat Na ____ today ____in AM
□ repeat K _____ today ____ in AM
________________ □ repeat Trop I
□ repeat 12L ECG
Chest/Lungs: □ others ___________________________
□yes □no
Findings if not MEDICATIONS:
Normal: □ Continue antiplatelets
□ Shift ISDN drip to __________
________________
CVS: DIET:
□yes □no □ Regular diet
Findings if not □ May have soft diet with aspiration precautions
Normal: □ Maintain on NPO

________________ OUTCOMES:
Abdomen: • No Dyspnea ☐ Yes ☐ No
□yes □no • No Chestpain ☐ Yes ☐ No
Findings if not • No hypotension ☐ Yes ☐ No
Normal:
• Stable comorbids ☐ Yes ☐ No
________________
Extremities:
□yes □no
Findings if not
Normal:

________________

Neuro:
□yes □no
Findings if not
Normal:

________________
Working
Impression:

BMC IM 2021 | Clinical Pathways | ACS

 DAY 4 DAY 4

SUBJECTIVE: □ Continue O2 supplement with

Symptoms □___ lpm via nasal cannula
□ chestpain □___ lpm via face mask
□ dyspnea □ Discontinue O2
□ headache □ Continue monitoring VS every ____ hours
BP ____ mmHg
OBJECTIVE: HR ____ beats/min
Vital Signs: RR ____ cycles/min
HR: _____ bpm O2 saturation: ____ %
BP: _____ mm Hg □ IV fluid to follow:
RR: _____ cpm ____ mL to run for____ mL/hr
Temp: _____ °C □ Shift to heplock
O2 sat: ____ % □ IV fluids to consume
(room air)
DIAGNOSTICS:
Normal? □ repeat CBC with platelet in AM
HEENT: □ repeat Chest Xray PA in AM
□yes □no □ repeat BUN ___ today ____in AM
Findings if not □ repeat Creatinine ____ today ____ in AM
Normal: □ repeat Na ____ today ____in AM
□ repeat K _____ today ____ in AM
________________ □ repeat Trop I
□ repeat 12L ECG
Chest/Lungs: □ others ___________________________
□yes □no
Findings if not
Normal: MEDICATIONS:
□ Continue antiplatelets
________________ □ Shift ISDN drip to __________
CVS:
□yes □no
Findings if not DIET:
Normal: □ Regular diet
□ May have soft diet with aspiration precautions
________________ □ Maintain on NPO
Abdomen:
□yes □no
Findings if not OUTCOMES:
Normal: • No Dyspnea ☐ Yes ☐ No
• No Chestpain ☐ Yes ☐ No
________________ • No hypotension ☐ Yes ☐ No
Extremities:
• Stable comorbids ☐ Yes ☐ No
□yes □no
Findings if not
Normal:

________________

Neuro:
□yes □no
Findings if not
Normal:

________________
Working
Impression:

BMC IM 2021 | Clinical Pathways | ACS

 DAY 5 DAY 5

SUBJECTIVE: □ Continue O2 supplement with

Symptoms □___ lpm via nasal cannula
□ chestpain □___ lpm via face mask
□ dyspnea □ Discontinue O2
□ headache □ Continue monitoring VS every ____ hours
BP ____ mmHg
OBJECTIVE: HR ____ beats/min
Vital Signs: RR ____ cycles/min
HR: _____ bpm O2 saturation: ____ %
BP: _____ mm Hg □ IV fluid to follow:
RR: _____ cpm ____ mL to run for____ mL/hr
Temp: _____ °C □ Shift to heplock
O2 sat: ____ % □ IV fluids to consume
(room air)
DIAGNOSTICS:
Normal? □ repeat CBC with platelet in AM
HEENT: □ repeat Chest Xray PA in AM
□yes □no □ repeat BUN ___ today ____in AM
Findings if not □ repeat Creatinine ____ today ____ in AM
Normal: □ repeat Na ____ today ____in AM
□ repeat K _____ today ____ in AM
________________ □ repeat Trop I
□ repeat 12L ECG
Chest/Lungs: □ others ___________________________
□yes □no
Findings if not
Normal: MEDICATIONS:
□ Continue antiplatelets
________________ □ Shift ISDN drip to __________
CVS:
□yes □no
Findings if not DIET:
Normal: □ Regular diet
□ May have soft diet with aspiration precautions
________________ □ Maintain on NPO
Abdomen:
□yes □no
Findings if not OUTCOMES:
Normal: • No Dyspnea ☐ Yes ☐ No
• No Chestpain ☐ Yes ☐ No
________________ • No hypotension ☐ Yes ☐ No
Extremities:
• Stable comorbids ☐ Yes ☐ No
□yes □no
Findings if not MAY GO HOME
Normal: Discharge Planning:
• May go home
________________
• Continue with discharge instructions.
Neuro:
□ Outcomes not met
□yes □no
□ Patient is for transfer to ICU
Findings if not
□ Patient has complications of ACS
Normal:
□ Patient has non resolving chestpain
□ Others________
________________
□ Exit the clinical pathway.
Final Diagnosis:

BMC IM 2021 | Clinical Pathways | ACS

VARIANCE CODES
A. PATIENT/FAMILY B. HEALTH PROVIDER C. BMC SYSTEMS D. OUTSIDE BMC

1. Patient/Family decision 1. Medical order 1. Delay in patient transfer 1. Condition/transportation

2. No funds 2. Provider’s decision 2. Delay in doing screening test 2. Home care availability

3. Other reasons 3. Other reasons 3. Other reasons

References:
• Harrison’s Principles of Internal Medicine

BMC IM 2021 | Clinical Pathways | ACS