Adrian M ED

[Date, month, year] 01, November, 2024 [Time] 14:35 _Presenting complaint_ Patient presents with acute chest pain. _History of presenting complaint_ - Patient reports sudden onset of sharp chest pain radiating to the left arm. - Pain is described as a 7/10 in severity. - Associated symptoms include shortness of breath and diaphoresis. - No recent history of trauma. Past medical history – Hypertension – Hyperlipidemia – Previous myocardial infarction Medication and allergies – Aspirin 81mg daily – Atorvastatin 20mg daily – _Penicillin allergy: hives_ Social history Patient is a retired teacher, non-smoker, and drinks alcohol socially. Lives with his wife and is independent in all activities of daily living. No current carer needs. Examination – Airway: Patent. – Breathing: Increased respiratory rate, bilateral equal air entry, oxygen saturation 92% on room air. – Circulation: Tachycardic, blood pressure 160/90 mmHg. – Neurological/Disability: GCS 15, pupils equal and reactive, limb power 5/5. – Exposure: No visible injuries. Investigations – ECG performed: ST-segment elevation in leads II, III, and aVF. – Cardiac enzymes ordered: Troponin I elevated. – Chest X-ray performed: No acute findings. Impression Acute myocardial infarction. Clinical management – Administered aspirin 325mg, oxygen via nasal cannula. – IV access established. – Morphine 2mg IV given for pain control. – Cardiology consult requested. – Patient admitted to the cardiac unit for further management. Consent Verbal consent obtained from patient.