Acute Medicine Specialist Template

Emergency Centre Assessment

A professional Acute Medicine Specialist template for healthcare professionals.

About this template

Streamline your emergency care documentation with our 'Emergency Centre Assessment' template, perfectly designed for acute medicine specialists. This robust clinical notes template ensures comprehensive capture of critical patient information, from presenting complaint and history to detailed examination findings, investigation results, and definitive plans. Acute care practitioners will find it invaluable for documenting urgent medical cases, ensuring no vital detail is missed during high-pressure situations. Heidi's AI scribe will intelligently populate each section, accurately extracting relevant clinical context from your patient consultations, enhancing efficiency and accuracy in the fast-paced emergency department environment. This template is your essential tool for structured, thorough, and compliant emergency medical records.

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Emergency Centre Assessment Presenting Complaint: 68-year-old male presenting with acute onset of severe, crushing central chest pain radiating to his left arm, accompanied by shortness of breath and profuse sweating, which started approximately 2 hours prior to arrival. History of Presenting Complaint: Patient reports sudden onset of 9/10 chest pain, described as crushing, non-positional, and unrelieved by rest. Associated symptoms include dyspnoea, diaphoresis, and nausea without vomiting. He denies any recent trauma, fever, or cough. Pain is consistent with previous descriptions of angina, but significantly more severe and prolonged. He reports feeling lightheaded and generally unwell. Functional impact includes inability to perform daily activities due to pain and breathlessness. Past Medical History: Known history of hypertension (diagnosed 10 years ago), hyperlipidaemia (diagnosed 5 years ago), and stable angina pectoris (diagnosed 3 years ago). He underwent an angioplasty with stent placement in LAD 2 years ago. No history of diabetes, stroke, or chronic kidney disease. Current medications: Aspirin 75mg OD, Atorvastatin 40mg OD, Ramipril 5mg OD, Bisoprolol 5mg OD, GTN spray PRN for angina. Patient denies taking any over-the-counter medications or herbal supplements recently. Known drug allergies: Penicillin (rash). Social History: Retired accountant, lives with his wife in a two-story house. Non-smoker for 15 years, occasional alcohol consumption (2-3 units per week). No illicit drug use. Moderate exercise history (daily walks) before the onset of current symptoms. Family history significant for premature coronary artery disease (father had MI at 55). On Examination: Vital signs: BP 100/60 mmHg, HR 110 bpm (regular), RR 24 breaths/min, SpO2 92% on room air, Temp 36.8°C. Relevant physical examination findings: Pale and diaphoretic. JVP not elevated. Chest clear to auscultation bilaterally, no added sounds. S1/S2 heart sounds, no murmurs, gallops, or rubs. Peripheral pulses weakly palpable. No peripheral oedema. Abdomen soft, non-tender. Mental state, mood or cognitive status: Alert and oriented to person, place, and time. Anxious and distressed due to pain, but cooperative. GCS 15. Investigations: ECG: Sinus tachycardia with ST elevation in leads V2-V5, aVL, and I, consistent with extensive anterior ST-elevation myocardial infarction (STEMI). Blood tests: Initial Troponin I 0.8 ng/mL (elevated, pending repeat), Creatinine 80 µmol/L, eGFR >90 mL/min/1.73m², Hb 14.2 g/dL, Platelets 250 x 10^9/L, INR 1.0. Glucose 7.2 mmol/L. Chest X-ray: Clear lung fields, no cardiomegaly or pleural effusion. Impression: Acute ST-elevation myocardial infarction (STEMI), likely extensive anterior, secondary to coronary artery disease. Patient is high risk given haemodynamic instability and extensive ECG changes. Red flags or clinical concerns identified: Haemodynamic instability (hypotension, tachycardia), significant ST elevation, acute onset severe chest pain. Differential diagnoses considered: Aortic dissection, pulmonary embolism, acute pericarditis, oesophageal rupture. Need for further investigations: Serial troponins, echocardiogram to assess cardiac function and wall motion abnormalities, urgent coronary angiography. Outcome / Discussion: Detailed discussion with patient and his wife regarding the suspected diagnosis of STEMI and the critical need for urgent reperfusion therapy (primary PCI). Risks and benefits of PCI, including bleeding, infection, and re-stenosis, were explained. Informed consent for immediate transfer to catheterisation lab obtained. Education, advice or counselling provided: Explained the importance of adhering to medication post-procedure and lifestyle modifications. Counselled on the need for cardiac rehabilitation. Follow-up arrangements discussed and agreed: Cardiology follow-up post-discharge arranged. Safety-netting advice including red flags and when to return: Advised patient and family on signs of recurrent chest pain, bleeding, or shortness of breath and to seek immediate medical attention if these occur. Plan: - Immediate activation of cath lab for primary percutaneous coronary intervention (PCI). - Administer aspirin 300mg chewable stat, ticagrelor 180mg loading dose, unfractionated heparin IV bolus as per protocol. - Initiate IV morphine for pain relief, metoclopramide for nausea. - Continuous cardiac monitoring and frequent vital sign observations. - IV fluids cautiously for hypotension, if needed, guided by clinical response. - NGT spray for residual angina if blood pressure allows. - Investigations ordered or pending: Repeat Troponin I in 3 hours, bedside echocardiogram post-PCI. - Referrals made to specialists or services: Cardiology team for ongoing management, Cardiac Rehabilitation liaison for post-discharge planning. - Follow-up plan including timeframe and location: Post-PCI in-patient care in CCU, then cardiology ward. Outpatient cardiology clinic follow-up at 6 weeks. - Safety-netting or contingency planning: In case of cardiac arrest, full resuscitation to be initiated. If PCI is delayed or unsuccessful, consider thrombolysis if within window and no contraindications.

Presenting Complaint: [brief description of presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) History of Presenting Complaint: [relevant history of presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [relevant symptoms and pertinent negatives] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [general condition or functional impact] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Past Medical History: [relevant past medical and surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [current medications, including OTC and supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [known drug or other allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Social History: [relevant social, occupational, family or living situation details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) On Examination: [vital signs, including any available observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [relevant physical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [mental state, mood or cognitive status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Investigations: [relevant diagnostic tests, imaging or pathology results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Impression: [summary of clinical impression or provisional diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [red flags or clinical concerns identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [differential diagnoses considered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [need for further investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Outcome / Discussion: [discussion with patient or family, including shared decision-making and consent] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [education, advice or counselling provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [follow-up arrangements discussed and agreed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [safety-netting advice including red flags and when to return] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: - [management and treatment plan including medications, procedures or therapies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [investigations ordered or pending] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [referrals made to specialists or services] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [follow-up plan including timeframe and location] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [safety-netting or contingency planning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)

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