Cardiac Complaint

Date: 1 November 2024 68y/o female, now with acute onset chest pain, secondary to suspected unstable angina, complicated by exertional dyspnoea. Medical History: # Hypertension: Well-controlled on amlodipine 5mg OD. Diagnosed 5 years ago. No complications. # Dyslipidaemia: Managed with atorvastatin 20mg OD. Diagnosed 3 years ago. # Previous appendicectomy: 20 years ago, no complications. # Allergies: Penicillin (rash). Social Factors: Smokes 10 cigarettes per day for 40 years. Consumes 10 units of alcohol per week. Retired school teacher, lives alone. Reports significant stress related to recent bereavement. Presenting Complaint: Patient reports central, crushing chest pain radiating to the left arm and jaw, starting approximately 3 hours ago. Pain is 7/10 at its worst, alleviated slightly by rest (SITUATION). Started suddenly while walking to the shop (ONSET). It is a constant, heavy, crushing sensation (CHARACTER). Radiates to the left arm and jaw (RADIATION). Current pain level is 5/10 (SEVERITY). No specific timing factors, but worse with exertion (TIMING). Associated symptoms include shortness of breath and sweating. Managed by sitting down and taking a paracetamol, which provided no relief. Relevant negatives: No history of similar pain, no fever, no cough, no recent trauma. Dyspnoea: Baseline NYHA class II, currently NYHA class III with minimal exertion. Physical Examination: Vital signs: BP: 145/90 mmHg HR: 88 bpm SATS: 95% on room air T: Apyrexic HGT: 5.8 mmol/L Hb: 13.2 g/dL General and other systems: General: Average build, mild pallor, no peripheral oedema, no cyanosis, appears distressed at rest. Respiratory system: Comfortable at rest, bilateral equal air entry, no adventitious sounds. Abdominal system: Soft, non-distended, non-tender, no masses or organomegaly, no scars or bruits. Neurological system: Alert and oriented x3, no focal neurological deficits. Musculoskeletal system: Normal range of motion in all major joints, no tenderness or swelling. Cardiovascular system: Inspection: No chest wall deformities, no scars, no pacemaker present. Palpation: Apex beat palpable in 5th intercostal space, mid-clavicular line. No thrills. Peripheral pulses present and symmetrical, normal rhythm, no delays. Auscultation: S1, S2 heard, no murmurs, no additional sounds, no carotid bruits. Bedside investigations: ECG shows ST depression in leads V4-V6. Rapid troponin pending. Assessment: 68-year-old female presenting with acute onset central crushing chest pain radiating to the left arm and jaw, associated with dyspnoea and diaphoresis. Highly suspicious for acute coronary syndrome, likely unstable angina given exertional nature and ECG changes. Differentials include myocardial infarction, aortic dissection, and pericarditis. Key supporting findings include classic chest pain presentation, exertional dyspnoea, and ECG abnormalities. Plan: 1. Biochemistry requested: Full blood count, electrolytes, renal function, liver function, cardiac enzymes (troponin I), B-type natriuretic peptide (BNP), lipids, HbA1c. 2. Imaging: Chest X-ray (CXR). 3. STAT medication: Aspirin 300mg chewable stat, GTN spray 2 puffs sublingual stat (if BP allows). 4. Pharmacology: Continue home medications, consider initiating clopidogrel after cardiology review. 5. Cardiologist opinion or referral: Urgent referral to cardiology for assessment and consideration of admission/further investigation (e.g., angiography). 6. Allied health referral: Cardiac rehabilitation referral post-discharge. 7. Counselled on: Symptoms of heart attack, importance of calling emergency services, medication adherence, smoking cessation, and dietary modifications. 8. Follow-up instructions: Follow up with GP in 3-5 days post-discharge or sooner if symptoms worsen. Tasks: Referral letter to cardiology, review rapid troponin results once available, follow up on CXR results.