Presenting complaint
- Presenting Issue: 45-year-old male presenting to the Emergency Department with sudden onset severe chest pain radiating to the left arm.
HPC
- Patient reports acute, sharp retrosternal chest pain, 8/10 intensity, starting approximately 2 hours prior to arrival. Pain radiates to the left shoulder and down the left arm. Associated symptoms include shortness of breath, diaphoresis, and nausea. Denies fever, cough, recent trauma, or history of similar pain. Pertinent positives: shortness of breath, diaphoresis, nausea. Pertinent negatives: no fever, no cough, no recent trauma. Systems review: Cardiovascular – chest pain, shortness of breath. Respiratory – no cough. Gastrointestinal – nausea, no vomiting, no abdominal pain. Neurological – no dizziness, no headache.
PMHx
- Hypertension, diagnosed 5 years ago, controlled with medication.
- Hypercholesterolaemia, diagnosed 3 years ago.
- No previous surgeries or hospitalizations.
Meds
- Amlodipine 5mg once daily
- Atorvastatin 20mg once daily
Allergies
- Penicillin (rash)
Social History
- Smokes 15 cigarettes per day for 20 years.
- Consumes alcohol socially, 2-3 units per week.
- Denies illicit drug use.
- Occupation: Office worker.
Family History
- Father died at 55 from myocardial infarction. Mother has Type 2 Diabetes Mellitus.
Obs
BP: 150/90 mmHg, HR: 105 bpm, RR: 22 breaths/min, Temp: 36.8°C, SpO2: 94% on room air.
OE
- General examination: Patient appears pale, diaphoretic, and in moderate distress. Alert and oriented x3.
- CVS: Tachycardic, S1S2 present, no murmurs, rubs, or gallops. Peripheral pulses palpable and equal bilaterally.
- Resp: Lungs clear to auscultation bilaterally, no wheezes or crackles. Good air entry.
- Abdo: Soft, non-tender, non-distended. Normal bowel sounds present. No guarding or rebound tenderness.
- MSK: No gross deformities. Full range of motion in all extremities. Strength 5/5 bilaterally. No peripheral oedema.
- Neuro: Mental status intact. Cranial nerves II-XII grossly intact. Coordination normal. Deep tendon reflexes 2+ bilaterally.
Impression
- Presumed diagnosis: Acute Myocardial Infarction (AMI) likely ST-Elevation Myocardial Infarction (STEMI).
- Differential diagnosis: Aortic dissection, Pulmonary Embolism, Pericarditis, Oesophageal spasm.
Plan/Treatment
- Investigations: 12-lead ECG (showing ST-segment elevation in inferior leads), serial cardiac troponins, chest X-ray, FBC, U&Es, LFTs, D-dimer.
- Management: Administer aspirin 300mg chewable, GTN spray, oxygen therapy via nasal cannula to maintain SpO2 >94%, morphine for pain relief. Establish IV access. Prepare for urgent cardiology consultation and potential primary PCI.
- Disposition: Admission to Cardiac Catheterisation Lab for urgent intervention.
