PEC - Admission

REASON FOR PRESENTATION: - Chest pain HISTORY OF PRESENTING ILLNESS: - 68yo Male - Wife present during consult - Onset of symptoms began approximately 2 hours prior to presentation. - Described as a crushing chest pain, radiating to the left arm, associated with shortness of breath. - Diaphoresis and nausea. - Possible trigger was shovelling snow this morning. - Patient has a history of hypertension and hyperlipidemia. - Patient was advised to take aspirin by his GP. - No relevant findings from system-specific review. PAST MEDICAL HISTORY: - Hypertension - Dr. Smith - Hyperlipidemia - Dr. Smith - Previous Myocardial Infarction - Dr. Smith MEDICATIONS: - Aspirin 81mg daily - Atorvastatin 20mg daily - Lisinopril 10mg daily ALLERGIES: - NKDA SOCIAL HISTORY: - Smoker, 20 pack-year history, quit 5 years ago. DRUG, TOBACCO, ALCOHOL HISTORY: - Drinks alcohol socially, 2-3 drinks per week. FAMILY HISTORY: - Father died of a heart attack at age 70. EXAMINATION: Vitals: - Weight: 80kg - Blood pressure: 160/90 mmHg - Heart rate: 100 beats/minute. - Oxygen saturation: 95% on room air. General: Appears in moderate distress, diaphoretic. CVS: S1 and S2 present, no murmurs, rubs, or gallops. Resp: Mildly labored breathing, clear to auscultation bilaterally. INVESTIGATIONS: Bloods: - sent to S&N Pathology - Troponin elevated - CK-MB elevated Radiology: - Chest X-ray: No acute findings. - ECG: ST-segment elevation in leads II, III, and aVF. ASSESSMENT: - Acute Myocardial Infarction (STEMI). MANAGEMENT IN EMERGENCY: - Aspirin 325mg given. - Oxygen administered via nasal cannula. - IV access established. - Morphine 2mg IV given for pain control. - Patient was given 0.4mg of sublingual GTN. - Patient was given 10mg of Metoprolol IV. - Outcome of treatment: Chest pain improved. PLAN: - Admission plan and team assignment - notified and accepted for admission - thanks - Details regards when the Admitting Doctor will see the patient: Admitting doctor will see the patient within the hour. - Details of any other Specialist Doctors asked to review patient, eg. consults and referrals - Cardiology consulted - notified and agrees to consult - thanks - Dietary instructions: NPO - Medication orders: Continue aspirin, atorvastatin, lisinopril, and metoprolol. Start heparin infusion. - Monitoring instructions: Continuous cardiac monitoring, frequent vital signs. - Disposition plan: Admit to the Cardiac Care Unit. Notes created using Heidi AI Medical Scribe | www.heidihealth.com