ED note

REASON FOR PRESENTATION: - Chest pain and shortness of breath HISTORY OF PRESENTING ILLNESS: - Onset of symptoms: 2 hours ago - Description of symptoms: Severe, crushing chest pain radiating to the left arm - Additional relevant symptoms: Nausea and sweating - Possible triggers or exposures: Physical exertion - Relevant background information: History of hypertension REVIEW OF SYSTEMS: - Cardiovascular: No palpitations, no previous episodes of chest pain - Respiratory: No cough, no wheezing MANAGEMENT EN ROUTE WITH QAS: - Details of treatment provided by QAS Ambulance enroute to Hospital: Oxygen therapy and aspirin administered - Outcome of treatment provided by QAS Ambulance enroute to Hospital: Partial relief of symptoms PAST MEDICAL HISTORY: - Hypertension - Appendectomy in 2010 MEDICATIONS: - Lisinopril 10 mg daily ALLERGIES: - Penicillin SOCIAL HISTORY: - Lives alone, works as a construction worker DRUG, TOBACCO, ALCOHOL HISTORY: - Alcohol: Social drinker - Tobacco: Smokes 10 cigarettes per day FAMILY HISTORY: - Father had a myocardial infarction at age 55 IMMUNISATION HISTORY: - Up to date with vaccinations EXAMINATION: Vitals: - Blood pressure: 150/90 mmHg - Heart rate: 95 beats/minute - Oxygen saturation: 94% on room air General: Alert, in mild distress CVS: Regular heart sounds, no murmurs Resp: Clear breath sounds bilaterally Abdo: Soft, non-tender Neuro: No focal neurological deficits INVESTIGATIONS: Bloods: - Troponin: Elevated Radiology: - Chest X-ray: No acute findings ASSESSMENT: - Primary diagnosis: Acute coronary syndrome - Secondary diagnoses or issues: Hypertension MANAGEMENT IN EMERGENCY: - Details of treatment provided in Emergency Department today: Administered nitroglycerin and morphine - Outcome of treatment provided in Emergency Department today: Significant relief of chest pain PLAN: - Admission plan and team assignment: Admit to Cardiology - Dietary instructions: Cardiac diet - Fluid management plan: IV fluids as needed - Medication orders: Continue aspirin, start beta-blocker - Consults and referrals: Cardiology consult - Monitoring instructions: Continuous cardiac monitoring - Disposition plan: Transfer to Cardiology unit