Date: 1 November 2024
68y/o female, now with acute onset chest pain, secondary to suspected unstable angina, complicated by exertional dyspnoea.
Medical History:
# Hypertension: Well-controlled on amlodipine 5mg OD. Diagnosed 5 years ago. No complications.
# Dyslipidaemia: Managed with atorvastatin 20mg OD. Diagnosed 3 years ago.
# Previous appendicectomy: 20 years ago, no complications.
# Allergies: Penicillin (rash).
Social Factors:
Smokes 10 cigarettes per day for 40 years. Consumes 10 units of alcohol per week. Retired school teacher, lives alone. Reports significant stress related to recent bereavement.
Presenting Complaint:
Patient reports central, crushing chest pain radiating to the left arm and jaw, starting approximately 3 hours ago. Pain is 7/10 at its worst, alleviated slightly by rest (SITUATION). Started suddenly while walking to the shop (ONSET). It is a constant, heavy, crushing sensation (CHARACTER). Radiates to the left arm and jaw (RADIATION). Current pain level is 5/10 (SEVERITY). No specific timing factors, but worse with exertion (TIMING). Associated symptoms include shortness of breath and sweating. Managed by sitting down and taking a paracetamol, which provided no relief. Relevant negatives: No history of similar pain, no fever, no cough, no recent trauma. Dyspnoea: Baseline NYHA class II, currently NYHA class III with minimal exertion.
Physical Examination:
Vital signs:
BP: 145/90 mmHg
HR: 88 bpm
SATS: 95% on room air
T: Apyrexic
HGT: 5.8 mmol/L
Hb: 13.2 g/dL
General and other systems:
General:
Average build, mild pallor, no peripheral oedema, no cyanosis, appears distressed at rest.
Respiratory system:
Comfortable at rest, bilateral equal air entry, no adventitious sounds.
Abdominal system:
Soft, non-distended, non-tender, no masses or organomegaly, no scars or bruits.
Neurological system:
Alert and oriented x3, no focal neurological deficits.
Musculoskeletal system:
Normal range of motion in all major joints, no tenderness or swelling.
Cardiovascular system:
Inspection:
No chest wall deformities, no scars, no pacemaker present.
Palpation:
Apex beat palpable in 5th intercostal space, mid-clavicular line. No thrills. Peripheral pulses present and symmetrical, normal rhythm, no delays.
Auscultation:
S1, S2 heard, no murmurs, no additional sounds, no carotid bruits.
Bedside investigations:
ECG shows ST depression in leads V4-V6. Rapid troponin pending.
Assessment:
68-year-old female presenting with acute onset central crushing chest pain radiating to the left arm and jaw, associated with dyspnoea and diaphoresis. Highly suspicious for acute coronary syndrome, likely unstable angina given exertional nature and ECG changes. Differentials include myocardial infarction, aortic dissection, and pericarditis. Key supporting findings include classic chest pain presentation, exertional dyspnoea, and ECG abnormalities.
Plan:
1. Biochemistry requested: Full blood count, electrolytes, renal function, liver function, cardiac enzymes (troponin I), B-type natriuretic peptide (BNP), lipids, HbA1c.
2. Imaging: Chest X-ray (CXR).
3. STAT medication: Aspirin 300mg chewable stat, GTN spray 2 puffs sublingual stat (if BP allows).
4. Pharmacology: Continue home medications, consider initiating clopidogrel after cardiology review.
5. Cardiologist opinion or referral: Urgent referral to cardiology for assessment and consideration of admission/further investigation (e.g., angiography).
6. Allied health referral: Cardiac rehabilitation referral post-discharge.
7. Counselled on: Symptoms of heart attack, importance of calling emergency services, medication adherence, smoking cessation, and dietary modifications.
8. Follow-up instructions: Follow up with GP in 3-5 days post-discharge or sooner if symptoms worsen.
Tasks:
Referral letter to cardiology, review rapid troponin results once available, follow up on CXR results.
Date: [Insert date of consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Insert age in years]y/o [Insert male or female], now with [Insert acute issue], secondary to [Insert cause] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.), complicated by [Insert complications] (Only include if explicitly mentioned or clearly supported by explicitly mentioned findings in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medical History:
# [Insert medical condition or past surgery with details of control/status, treatment, complications, dates, surgeon, and relevant investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
# Allergies: [Insert drug/food/insect allergies with severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social Factors:
[Insert relevant social history including smoking, alcohol, drug use, lifestyle habits, and stressors with quantities if stated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Presenting Complaint:
[Insert presenting complaint with associated factors, progression, management tried, and relevant negatives. If pain is described, structure using the SOCRATES framework. If dyspnoea is described, include baseline and current NYHA class.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Physical Examination:
Vital signs:
BP: [Insert blood pressure in mmHg] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HR: [Insert heart rate in bpm] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SATS: [Insert oxygen saturation with oxygen modality] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
T: [Insert temperature in °C or state apyrexic] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HGT: [Insert glucose in mmol/L] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Hb: [Insert haemoglobin value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
General and other systems:
General:
[Insert build, presence or absence of pallor, oedema, cyanosis, and distress at rest] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Respiratory system:
[Insert respiratory findings including comfort at rest, air entry, symmetry, and adventitious sounds with location and timing] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Abdominal system:
[Insert abdominal findings including distension, tenderness, peritonism, masses, organomegaly, scars, or bruits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Neurological system:
[Insert neurological examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Musculoskeletal system:
[Insert musculoskeletal examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Cardiovascular system:
Inspection:
[Insert chest wall findings, scars, masses, pacemaker presence] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Palpation:
[Insert apex beat location, thrills, peripheral pulse quality, rhythm, symmetry, and delays] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Percussion:
[Insert cardiac percussion findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Auscultation:
[Insert heart sounds, murmurs with timing, radiation, additional sounds, and carotid bruits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Bedside investigations:
[Insert bedside investigation findings such as ECG or rapid troponin] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment:
[Insert clinical assessment including working diagnosis, differentials, key supporting findings, and complications] (Only include if explicitly mentioned or clearly summarised from explicitly mentioned information in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
1. Biochemistry requested: [Insert blood investigations requested] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2. Imaging: [Insert imaging ordered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
3. STAT medication: [Insert urgent medication with name, dose, route, and time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
4. Pharmacology: [Insert medication changes or new prescriptions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
5. Cardiologist opinion or referral: [Insert advice or referral details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
6. Allied health referral: [Insert allied health referrals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
7. Counselled on: [Insert counselling topics discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
8. Follow-up instructions: [Insert follow-up instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Tasks:
[Insert specific follow-up tasks such as referrals, results to review, or letters to complete] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include information if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely. Never use direct quotations. Never invent patient details, diagnoses, examination findings, interpretations, plans, or tasks. Use only the transcript, contextual notes or clinical note as the source of truth. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing; simply omit the placeholder or section entirely.)
