Emergency Medicine Custom Template

Emergency Medicine Doctor 34-year-old female Chief Complaint: Acute onset of severe, crushing chest pain radiating to the left arm, accompanied by shortness of breath. History of Present Illness: Patient presented to the emergency department via ambulance after experiencing sudden onset of severe, substernal chest pain approximately 2 hours prior to arrival. The pain is described as a 9/10 crushing sensation, radiating down her left arm and into her jaw. She reports associated shortness of breath, diaphoresis, and nausea without vomiting. She denies any recent trauma or heavy exertion. This is the first time she has experienced chest pain of this severity. She has no recent visits or hospital admissions for similar complaints. No previous occurrences of current symptoms. No related visits, investigations, management, or diagnoses for chest pain. She has not taken any medications for this episode prior to arrival. Associated symptoms include diaphoresis, nausea, and mild lightheadedness. Patient works as an office administrator, denies illicit drug use, and states she leads a moderately active lifestyle. Past Medical History (not comprehensive): - Hypertension (diagnosed 2 years ago, controlled with medication) - Hyperlipidaemia (diagnosed 1 year ago, on statin therapy) - Family history: Father had a myocardial infarction at age 55; mother has type 2 diabetes. - Social history: Smokes 5 cigarettes per day for 15 years, occasional alcohol consumption (2 units per week), denies recreational drug use. Medications (not comprehensive): - Amlodipine 5mg once daily - Atorvastatin 20mg once daily Allergies: - Penicillin (rash) Review of Systems: Cardiovascular: Positive for chest pain, radiation to left arm and jaw, palpitations. Negative for oedema. Respiratory: Positive for shortness of breath. Negative for cough, wheeze, sputum. Gastrointestinal: Positive for nausea. Negative for vomiting, diarrhoea, constipation. Neurological: Positive for mild lightheadedness. Negative for syncope, focal weakness, paraesthesia. Physical Examination: - General Appearance: Acutely distressed female, pale and diaphoretic, clutching her chest. - Vital Signs: Temperature 36.8°C, Blood pressure 148/92 mmHg, Heart rate 110 bpm (regular), Respiratory rate 22 breaths per minute, Oxygen saturation 94% on room air. - HEENT: Normocephalic, atraumatic. Pupils equal, round, reactive to light. Sclerae anicteric. Oropharynx clear. - Respiratory: Symmetrical chest expansion. Clear breath sounds bilaterally, no crackles or wheeze. Good air entry throughout. - Cardiac: Tachycardic, S1S2 audible, no murmurs, rubs, or gallops. Capillary refill <2 seconds. - Abdominal: Soft, non-tender to palpation in all quadrants. No organomegaly or masses. - Skin: Pale, clammy, no rashes or lesions observed. - Other: Peripheral pulses 2+ and symmetrical in all four limbs. Side Room Investigations: - HGT: 6.2 mmol/L - Haemoglobin: 13.5 g/dL Assessment: - Acute Myocardial Infarction - Differential Diagnoses: 1. Aortic Dissection 2. Pulmonary Embolism 3. Pericarditis Plan: - Overall plan: Immediate cardiac workup. Administer aspirin, nitroglycerin, and morphine. Consult cardiology. Prepare for potential primary percutaneous coronary intervention (PCI). Admit to Coronary Care Unit (CCU). - Recommended medications: Aspirin 300mg chewable stat, Glyceryl trinitrate (GTN) spray 2 puffs sublingually, Morphine 2-4mg IV as needed for pain, Ticagrelor 180mg loading dose, Heparin infusion as per protocol. - General patient care advice: Advise patient to remain calm, limit movement, and report any changes in symptoms immediately. Provide emotional support. - Danger signs that would prompt a return to the emergency department: Worsening chest pain despite medication, increasing shortness of breath, new onset of confusion or weakness, collapse. - Follow-up recommendations: Cardiology follow-up post-discharge, lifestyle modifications including smoking cessation and dietary changes, cardiac rehabilitation programme referral. Investigations: - Results of basic blood work: Trop I 0.8 ng/mL (elevated), CK-MB 120 U/L (elevated), FBC, U&Es, LFTs within normal limits. - Results of any imaging performed: Chest X-ray – clear lung fields, normal cardiac silhouette. No evidence of pneumothorax or pleural effusion. - Electrocardiogram findings: ST elevation in leads II, III, aVF (inferior MI). Final/Working Diagnosis: - Final diagnosis - Primary diagnosis: Acute Inferior Myocardial Infarction with supporting rationale of classic symptoms (crushing chest pain radiating to left arm), elevated cardiac biomarkers (Trop I, CK-MB), and characteristic ECG changes (ST elevation in inferior leads).