Paramedic Patient Clinical Assessment Note

Paramedic Patient Clinical Assessment Note Global Overview: * Entry gained via unlocked front door following call from concerned neighbour. Patient found supine on living room floor, conscious but disoriented. General appearance: pale, diaphoretic. Neighbour, Mrs. Sylvia Greene, was present. Call originated from neighbour's landline. No immediate safety concerns identified. Presenting Complaint (PC): Sudden onset of severe, crushing central chest pain radiating to the left arm, associated with shortness of breath and nausea, approximately 30 minutes prior to call. History of Presenting Complaint (HPC): Patient reports sudden onset of central chest pain while watching television. The pain rapidly intensified, becoming crushing in nature and radiating down his left arm. He experienced associated shortness of breath, feeling like he couldn't get enough air, and mild nausea without vomiting. He denies any recent strenuous activity or trauma. The pain has been constant since onset and has not been relieved by resting or changing position. He has no previous similar episodes. Past Medical History: Hypertension (diagnosed 2010), Type 2 Diabetes Mellitus (diagnosed 2015), Hyperlipidaemia (diagnosed 2018) On Examination (OE): Patient is a 68-year-old male, conscious but appears distressed and in considerable pain. Skin is pale and clammy. Peripheral pulses are weak but regular. Chest examination reveals equal bilateral breath sounds with no added sounds. Abdomen is soft, non-tender, and non-distended. No peripheral oedema noted. Cranial Nerve Assessment: CN I (Olfactory): NOT CHECKED CN II (Optic): Pupils equal and reactive to light, visual fields intact by confrontation CN III (Oculomotor): Full extraocular movements CN IV (Trochlear): Full extraocular movements CN V (Trigeminal): Sensation intact to light touch in all three divisions bilaterally, masseter strength symmetrical CN VI (Abducens): Full extraocular movements CN VII (Facial): Symmetrical facial expressions CN VIII (Vestibulocochlear): Hearing grossly intact bilaterally CN IX (Glossopharyngeal): Gag reflex present CN X (Vagus): Uvula elevates centrally on phonation CN XI (Accessory): Shoulder shrug and head turn against resistance strong and symmetrical CN XII (Hypoglossal): Tongue protrudes in midline, no fasciculations DANISH Assessment: D – Dysdiadochokinesis: Not checked: patient in acute distress A – Ataxia (gait/coordination): Not checked: patient supine N – Nystagmus: No nystagmus observed on direct gaze or extreme lateral gaze I – Intention tremor: No intention tremor observed S – Speech (dysarthria): Speech clear, no dysarthria H – Head impulse test (HIT): Not checked: patient in acute distress Observations: Initial Observations — 10:35 GMT on 1 November 2024: Heart Rate (HR): 108 bpm Blood Pressure (BP): 148/92 mmHg Respiratory Rate (RR): 22 breaths per minute Oxygen Saturations (SpO₂): 92 % Temperature (Temp): 36.7 °C Capillary Refill Time (CRT): 3 seconds Level of Consciousness (GCS/AVPU): A (Alert) End Tidal CO₂: 38 mmHg Pulse Character: Weak, thready ECG Rhythm: Sinus tachycardia with ST elevation in leads II, III, aVF Pupils (size and reactivity): 3mm, briskly reactive bilaterally Repeat Observations — 10:45 GMT on 1 November 2024: Heart Rate (HR): 102 bpm Blood Pressure (BP): 135/88 mmHg Respiratory Rate (RR): 20 breaths per minute Oxygen Saturations (SpO₂): 95 % (on 4L O2 via nasal cannula) Temperature (Temp): 36.8 °C Capillary Refill Time (CRT): 2 seconds Level of Consciousness (GCS/AVPU): A (Alert) End Tidal CO₂: 36 mmHg Pulse Character: Regular, slightly stronger ECG Rhythm: Sinus tachycardia, ST elevation persisting Pupils (size and reactivity): 3mm, briskly reactive bilaterally Blood Results: Capillary Glucose: 8.9 mmol/L Urinalysis: Leukocytes: Negative Nitrates: Negative Urobilinogen: Normal Protein: Negative pH: 6.0 Haematuria: Negative Specific Gravity: 1.020 Ketones: Negative Bilirubin: Negative Glucose: Negative Medication History (MHx): * Lisinopril 10mg once daily, compliant * Metformin 500mg twice daily, compliant * Atorvastatin 20mg once daily, compliant Allergies: Penicillin (rash) Family History (FHx): * Father: Myocardial infarction at age 55 * Mother: Type 2 Diabetes Social History (SHx): Patient lives alone in a terraced house. Retired painter and decorator. Smokes 10 cigarettes per day for 40 years. Drinks 15-20 units of alcohol per week. No illicit drug use. Baseline level of function is independent for all activities of daily living. Working Diagnosis: Acute Inferior Myocardial Infarction Differential Diagnosis: * Acute Aortic Dissection * Pulmonary Embolism * Oesophageal Spasm Plan: * Administer Aspirin 300mg orally * Administer Glyceryl Trinitrate (GTN) spray 2 puffs sublingually (repeated once) * Administer Morphine 2mg IV for pain relief * Initiate oxygen therapy via nasal cannula at 4L/min * Establish IV access (18G cannula in left antecubital fossa) * Pre-alert receiving hospital (cardiac catheterisation lab activation) * Transport to hospital with continuous ECG monitoring * Provide reassurance and ongoing pain assessment Decision Making Rationale: * Working Diagnosis: Acute Inferior Myocardial Infarction * Supporting factors: Classic crushing chest pain radiating to left arm, associated shortness of breath and nausea, ST elevation in inferior leads (II, III, aVF) on ECG, diaphoretic appearance, history of cardiovascular risk factors (hypertension, hyperlipidaemia, diabetes, smoking). * Contradicting factors: None identified. * Management Plan: * Supporting factors: Adherence to acute coronary syndrome guidelines (Aspirin, GTN, Morphine, Oxygen), rapid transport to definitive care (PCI capable centre), continuous monitoring due to dynamic nature of condition. * Contradicting factors: None identified. Worsening / Recontact Advice: * Advised patient's neighbour that paramedics are en route to hospital and to contact emergency services again if patient's condition deteriorates further or if any new symptoms develop. Clinical Discussions / Advice Sought: Discussion with "Dr. Sarah Johnson" (Emergency Department Consultant, City General Hospital) via telephone at 10:40 GMT regarding initial ECG findings and patient presentation. Outcome was agreement on pre-alerting for PCI and direct transport to cardiac catheterisation lab. Dr. Johnson acknowledged the provisional diagnosis of inferior STEMI and confirmed bed availability.