ED Assessment AEC

ED Reg Dr. Sarah Chen Discussed with SMO PC/ 68-year-old male presenting with acute onset central chest pain radiating to the left arm. HPC/ Patient reports sudden, severe central chest pain starting approximately 2 hours prior to arrival. Pain is described as a crushing sensation, 8/10 in intensity, and constant. It radiates to his left arm and jaw. He reports associated shortness of breath, diaphoresis, and mild nausea but no vomiting. He denies any fever, cough, recent trauma, or history of similar pain. He has taken 3 doses of sublingual GTN without significant relief. Generally, the patient appears distressed and diaphoretic. PMH/ Hypertension, Hyperlipidaemia, Type 2 Diabetes Mellitus. History of angioplasty 5 years ago. DH/ * Atorvastatin 40mg OD * Ramipril 10mg OD * Metformin 500mg BD * Aspirin 75mg OD Allergies: Penicillin - rash SH/ Lives with his wife. Lives in a two-story house. Smoking status: Ex-smoker (quit 10 years ago), previously 20 pack-years. Alcohol consumption: Occasional social drinker (1-2 units/week). Recreational drug use: Denies. Functional baseline: Independent with all ADLs, walks 30 minutes daily. O/E/ Vitals: BP: 145/90 mmHg HR: 98 bpm (regular) RR: 22 breaths/min SpO2: 95% on room air Temp: 36.8°C GCS: 15 Chest: Symmetrical chest expansion, clear breath sounds bilaterally, no crepitations or wheeze. No tenderness to palpation. Abdo: Soft, non-tender, non-distended. Bowel sounds present. Neuro: Alert and oriented to time, place, person. Cranial nerves intact. No focal neurological deficits. Lower limbs: No oedema, pulses 2+ bilaterally. Capillary refill <2 seconds. Upper limbs: No oedema, pulses 2+ bilaterally. Capillary refill <2 seconds. Investigations/ VBG: pH 7.35, pCO2 48 mmHg, pO2 55 mmHg, Bicarb 25 mmol/L, Lactate 2.1 mmol/L. Mild respiratory acidosis, elevated lactate. Bloods: * Troponin T: 0.15 ng/mL (elevated) * FBC: WCC 10.2 x 10^9/L, Hb 14.0 g/dL, Plt 250 x 10^9/L * U&E: Na 138 mmol/L, K 4.1 mmol/L, Creatinine 90 µmol/L * Glucose: 8.5 mmol/L ECG: Sinus tachycardia, ST elevation in leads II, III, aVF (inferior STEMI). CXR: Normal cardiac silhouette, clear lung fields, no pneumothorax or pleural effusion. Other imaging: N/A IMP/ Acute Inferior ST-Elevation Myocardial Infarction (STEMI) likely due to acute coronary syndrome. Patient is haemodynamically stable but distressed, requiring immediate cardiac intervention. Red flags: Ongoing chest pain, elevated troponin, classic ECG changes (STEMI). PLAN/ D/w snr Discussed with patient and wife the diagnosis of a heart attack and the need for urgent cardiac catheterisation. Patient understands and consents. Agreed management plan includes immediate transfer to cath lab. Education provided to patient and family regarding STEMI, the procedure, and what to expect post-procedure. Emphasised the importance of not delaying seeking care for similar symptoms in the future. Follow-up arrangements: Post-PCI care in CCU, then cardiology ward. Follow-up with cardiology outpatient clinic arranged post-discharge. Red flags discussed: Any recurrence of chest pain, severe shortness of breath, sudden weakness or dizziness, or palpitation warrant immediate return to the emergency department or calling emergency services. Further investigations required: Pre-cath lab bloods, full cardiac workup post-PCI.