PEC - Admission

REASON FOR PRESENTATION: - Chest pain HISTORY OF PRESENTING ILLNESS: - 68yo Male - Wife, Mary Smith, present during consult - Onset of symptoms: Sudden onset of chest pain approximately 30 minutes prior to presentation. - Description of symptoms: Crushing chest pain radiating to the left arm, associated with shortness of breath. - Additional relevant symptoms: Diaphoresis and nausea. - Possible triggers or exposures: Patient was mowing the lawn when symptoms started. - Relevant background information: Patient has a history of hypertension and hyperlipidemia. - Recent advice or management given by other doctors: None. - Relevant findings from system-specific review: Denies any recent fever, cough, or other respiratory symptoms. PAST MEDICAL HISTORY: - Hypertension - Dr. Jones - Hyperlipidemia - Dr. Jones MEDICATIONS: - Lisinopril 20mg daily - Atorvastatin 40mg daily ALLERGIES: - NKDA SOCIAL HISTORY: - Smokes 1 pack of cigarettes per day for 40 years. DRUG, TOBACCO, ALCOHOL HISTORY: - Smokes 1 pack of cigarettes per day. - Drinks alcohol socially, approximately 2-3 drinks per week. FAMILY HISTORY: - Father died of a myocardial infarction at age 65. EXAMINATION: Vitals: - Heart rate: 110 beats/minute. - Blood pressure: 160/90 mmHg. - Oxygen saturation: 94% General: Appears anxious and in moderate distress. CVS: Regular rhythm, no murmurs, rubs, or gallops. Resp: Bilateral clear lung sounds. Abdo: Soft, non-tender. Neuro: Alert and oriented. INVESTIGATIONS: Bloods: - sent to S&N Pathology - Troponin elevated. - CBC and CMP pending. Radiology: - Chest X-ray: No acute findings. ECG and Cardiac Monitoring - ECG: ST-segment elevation in leads II, III, and aVF. ASSESSMENT: - Acute myocardial infarction. MANAGEMENT IN EMERGENCY: - Aspirin 325mg given. - Oxygen administered via nasal cannula. - IV access established. - Morphine 2mg IV given for pain control. - ECG performed. - Cardiology consulted. - Patient transferred to the cardiac catheterization lab. - Outcome of treatment provided in Emergency Department today: Patient's pain improved with morphine. PLAN: - Admission plan and team assignment: Admitted to the Cardiac Care Unit - notified and accepted for admission - thanks - Details regards when the Admitting Doctor will see the patient: Admitting Doctor will see the patient within the hour. - Details of any other Specialist Doctors asked to review patient, eg. consults and referrals: Cardiology consulted - notified and agrees to consult - thanks - Dietary instructions: NPO. - Medication orders: Continue aspirin, start heparin drip, and continue lisinopril and atorvastatin. - Monitoring instructions: Continuous cardiac monitoring and frequent vital signs. - Disposition plan: Patient to be admitted to the Cardiac Care Unit for further management. Notes created using Heidi AI Medical Scribe |,www.heidihealth.com