NWRI

NON-WORK RELATED INJURY/ILLNESS Days left on swing: 3 days left, home on Friday. Employer: Acme Corp, Manufacturing Department Role: Production Line Worker Meds: As recorded Allergies: As recorded Relevant Past History: As recorded HPC: The patient presents to the emergency department today with complaints of sudden onset of severe chest pain. The pain is described as crushing and radiating to the left arm. The patient states the pain started approximately 30 minutes prior to arrival and was not preceded by any specific activity. The patient denies any recent trauma. Exam: The patient is alert and oriented, but appears to be in significant distress due to chest pain. Blood pressure is 160/90 mmHg, heart rate is 110 bpm, respiratory rate is 24 breaths per minute, and oxygen saturation is 94% on room air. The patient is diaphoretic. Cardiac auscultation reveals a regular rhythm with no murmurs, rubs, or gallops. Lung sounds are clear bilaterally. The abdomen is soft and non-tender. There is no peripheral oedema. The patient is afebrile. General: The patient reports feeling fatigued and has been experiencing some night sweats over the past week. Cardiovascular: The patient reports severe, crushing chest pain radiating to the left arm. Denies any palpitations or orthopnoea. Respiratory: The patient denies any cough, sputum, or wheezing. Musculoskeletal: The patient denies any arthralgia, myalgia, or joint swelling. Obs: 160/90 mmHg, 110 bpm, 37.1°C, 94% Impression: Acute myocardial infarction. Consult: Dr. Smith (Cardiologist) was consulted. Plan: Reassurance provided. Aspirin 325mg chewed and swallowed. Oxygen administered via nasal cannula at 2L/min. IV access established. ECG obtained and interpreted, showing ST-segment elevation in leads II, III, and aVF. Patient was transferred to the cardiac catheterisation lab for further evaluation and intervention. Review: The patient will be reviewed by the cardiology team in the morning.