Tonga ED notes

[Date, month, year] 1 November 2024 [Time] 14:35 **Presenting complaint** Chest pain **History of presenting complaint** - Patient reports sudden onset of sharp chest pain radiating to the left arm. - Pain began approximately 30 minutes prior to arrival. - Associated with shortness of breath and diaphoresis. - No recent trauma. - No alleviating factors. - Pain is worsened by deep inspiration. **Past medical history** - Hypertension - Hyperlipidemia **Medication and allergies** - Aspirin 75mg daily - Atorvastatin 20mg nocte - _NKDA_ **Social history** - Smoker, 20 cigarettes per day. - Works as a construction worker. - Independent with ADLs. - No known social issues. **Examination** - Airway: Patent. - Breathing: Increased respiratory rate, bilateral equal air entry, SpO2 94% on room air. - Circulation: Tachycardic, BP 160/90 mmHg, peripheral pulses palpable. - Disability/Neurological: Alert and oriented, GCS 15. - Exposure/Other injury or physical findings: Diaphoretic, no obvious injury. **Investigations** - ECG performed at 14:40, showing ST-segment elevation in leads II, III, and aVF. - Cardiac enzymes pending. **Impression** Acute myocardial infarction. **Clinical management** - Administered 300mg Aspirin PO. - Administered 5mg Morphine IV. **Consent** "Verbal consent obtained from patient" [Dr. Emily Carter, Emergency Medicine Specialist, GMC 1234567]