Primary Care Consultation Template

Clinician Specialty: Advanced Paramedic Verbal consent for use of Heidi AI scribe and option for opt out. Chaperone: Patient declined a chaperone during the examination. Summary of Appointment: The patient presented with a sudden onset of severe, crushing chest pain radiating to the left arm and jaw, associated with shortness of breath and diaphoresis. An initial assessment indicated a high likelihood of an acute cardiac event. The patient was stabilised and immediately referred for emergency hospital assessment. Presenting Complaint: The patient, a 58-year-old male, called emergency services reporting acute, severe central chest pain that began approximately 30 minutes prior to the call. He described the pain as 'crushing' and stated it was 9/10 in severity, accompanied by difficulty breathing and profuse sweating. He also reported radiation of the pain to his left arm and jaw. He denied any recent trauma or exertion prior to the onset of symptoms. History: The patient reported a 5-year history of hypertension, managed with ramipril, and hypercholesterolaemia, managed with atorvastatin. He has no known allergies. He reported a family history of ischaemic heart disease; his father had a myocardial infarction at age 62. He is a former smoker, having quit 10 years ago, and occasionally drinks alcohol. There is no personal history of diabetes or previous cardiac events. The onset of the current symptoms was sudden and without a clear precipitating factor. Symptoms: Severe, crushing central chest pain, rated 9/10, radiating to the left arm and jaw. Associated symptoms include significant shortness of breath, described as difficulty catching his breath, and profuse diaphoresis (sweating). He also reported mild nausea but denied vomiting. No fever, cough, or recent illness. He denied any leg swelling or calf pain. There was no complaint of dizziness or syncope. The pain is constant and has not abated since its onset. Exclusions of Red Flags: No evidence of pulmonary embolism (no calf swelling, unilateral leg pain, or recent long-haul travel). No signs of aortic dissection (no sharp, tearing pain radiating to the back, no blood pressure differential between arms). No signs of pneumothorax (bilateral breath sounds present, no history of recent chest trauma or lung disease). Examination: Observations: Blood Pressure: 160/95 mmHg (right arm, sitting) Heart Rate: 110 bpm, regular Respiratory Rate: 24 breaths per minute Oxygen Saturation: 92% on room air Temperature: 36.8°C Capillary Refill Time: <2 seconds Narrative Findings: Patient is pale, clammy, and clearly distressed, clutching his chest. Respiratory effort is increased, but no accessory muscle use observed. Jugular venous pressure not elevated. S1 and S2 heart sounds audible; no murmurs or rubs heard. Bilateral breath sounds are clear to auscultation with no added sounds. Abdomen is soft, non-tender, and non-distended. Peripheral pulses are palpable and equal bilaterally. No peripheral oedema. Neurological examination grossly intact, conscious and alert. Social: The patient lives with his wife in a two-storey house. He is retired from a job as a mechanic. He has good social support from his family. No recent significant life stressors reported other than the current health event. Plan: Administered 300mg aspirin orally and 0.4mg glyceryl trinitrate spray sublingually (repeated once after 5 minutes with some pain reduction). Oxygen administered via non-rebreather mask at 15 L/min, improving SpO2 to 96%. IV access established with 18G cannula in left antecubital fossa. 12-lead ECG performed showing ST elevation in leads II, III, aVF, and V3-V6, consistent with acute myocardial infarction. Immediate pre-alert to nearest Percutaneous Coronary Intervention (PCI) centre initiated. Patient transferred via emergency ambulance for direct admission to cardiology.