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.
Global Overview:
[Overview of how entry was gained, where the patient was found, their position and general appearance, who else was present, where the call originated from and any immediate safety concerns] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points.)
Presenting Complaint (PC):
[Patient's main presenting symptom or symptoms and duration of the current issue] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write concisely and keep symptom-focused. Do not include direct patient quotes.)
History of Presenting Complaint (HPC):
[Chronological account of symptoms including onset, duration, progression, nature, severity, associated symptoms, exacerbating and relieving factors, timing and any previous episodes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Include patient-reported information only. Do not include examination findings or clinical interpretation. Write in paragraphs of full sentences.)
Past Medical History:
[Previous medical conditions ordered by clinical relevance to the presenting complaint, including date of diagnosis or relevant timeframe where stated] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use standard medical abbreviations where appropriate. Do not include current symptoms, medications or clinical interpretation. Write as a comma-separated list on a single line.)
On Examination (OE):
[Objective examination findings including general appearance and relevant system examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Exclude patient-reported symptoms. Write in paragraphs of full sentences.)
Cranial Nerve Assessment:
(Only include if a cranial nerve assessment or neurological examination is explicitly undertaken in transcript, contextual notes or clinical note, else omit section entirely. List each cranial nerve individually. If a nerve is not assessed, document as "NOT CHECKED". If a reason is provided for omission, document in lower case as "not checked: [reason]". Do not infer or complete missing findings.)
CN I (Olfactory): [Olfactory nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
CN II (Optic): [Optic nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
CN III (Oculomotor): [Oculomotor nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
CN IV (Trochlear): [Trochlear nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
CN V (Trigeminal): [Trigeminal nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
CN VI (Abducens): [Abducens nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
CN VII (Facial): [Facial nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
CN VIII (Vestibulocochlear): [Vestibulocochlear nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
CN IX (Glossopharyngeal): [Glossopharyngeal nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
CN X (Vagus): [Vagus nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
CN XI (Accessory): [Accessory nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
CN XII (Hypoglossal): [Hypoglossal nerve findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
DANISH Assessment:
(Only include if dizziness or vertigo is reported or a cranial nerve or neurological assessment is undertaken in transcript, contextual notes or clinical note, else omit section entirely. If a reason is provided for any omission, document the reason.)
D – Dysdiadochokinesis: [Dysdiadochokinesis assessment findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
A – Ataxia (gait/coordination): [Ataxia and gait or coordination assessment findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
N – Nystagmus: [Nystagmus assessment findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
I – Intention tremor: [Intention tremor assessment findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
S – Speech (dysarthria): [Speech and dysarthria assessment findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
H – Head impulse test (HIT): [Head impulse test findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NOT CHECKED".)
Observations:
Initial Observations — [Time of initial observations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.):
Heart Rate (HR): [Heart rate value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Blood Pressure (BP): [Blood pressure value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Respiratory Rate (RR): [Respiratory rate value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Oxygen Saturations (SpO₂): [Oxygen saturation value and percentage] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Temperature (Temp): [Temperature value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Capillary Refill Time (CRT): [Capillary refill time value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Level of Consciousness (GCS/AVPU): [Level of consciousness using GCS or AVPU scale] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
End Tidal CO₂: [End tidal CO₂ value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Pulse Character: [Pulse character description] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
ECG Rhythm: [ECG rhythm findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Pupils (size and reactivity): [Pupil size and reactivity findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Repeat Observations — [Time of repeat observations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.):
Heart Rate (HR): [Heart rate value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Blood Pressure (BP): [Blood pressure value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Respiratory Rate (RR): [Respiratory rate value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Oxygen Saturations (SpO₂): [Oxygen saturation value and percentage] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Temperature (Temp): [Temperature value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Capillary Refill Time (CRT): [Capillary refill time value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Level of Consciousness (GCS/AVPU): [Level of consciousness using GCS or AVPU scale] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
End Tidal CO₂: [End tidal CO₂ value and units] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Pulse Character: [Pulse character description] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
ECG Rhythm: [ECG rhythm findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Pupils (size and reactivity): [Pupil size and reactivity findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
(Repeat this observations block for each additional set of observations documented.)
Blood Results:
[Blood investigation results documented without clinical interpretation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.)
Urinalysis:
(Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Leukocytes: [Leukocytes result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Nitrates: [Nitrates result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Urobilinogen: [Urobilinogen result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Protein: [Protein result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
pH: [Urinary pH result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Haematuria: [Haematuria result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Specific Gravity: [Specific gravity result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Ketones: [Ketones result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Bilirubin: [Bilirubin result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Glucose: [Urinary glucose result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else leave blank.)
Medication History (MHx):
[Current medications including name, dose, frequency, compliance and any recent changes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use standard medication abbreviations where appropriate. Write as a list.)
Allergies:
[Known allergies and the type of reaction associated with each] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If no known drug allergies are explicitly stated, write: "NKDA".)
Family History (FHx):
[Relevant family medical history including relationship to patient and condition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.)
Social History (SHx):
[Relevant social history including smoking status, alcohol and drug use, occupation, living situation and baseline level of function] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Working Diagnosis:
[Clinician's explicitly stated working diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write concisely without rationale.)
Differential Diagnosis:
[Clinician's explicitly stated differential diagnoses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write as a bullet point list without rationale.)
Plan:
[Management plan including investigations ordered, treatments prescribed, follow-up arrangements and patient education] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points.)
Decision Making Rationale:
[Rationale for the working diagnosis and management plan including supporting and contradicting factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write each point with supporting and contradicting factors as bullet points.)
Worsening / Recontact Advice:
[Worsening, safety netting or recontact advice given to the patient, their friends, relatives or carers] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points.)
Clinical Discussions / Advice Sought:
[Summary of any conversations with other clinicians regarding patient care, including the reason for the discussion, the outcome, and the full name, role and organisation of the person consulted] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in the first person in paragraphs of full sentences.)
