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Subjective:

CC (Chief Complaint): Patient, a 55-year-old male, presents with severe chest pain.

HPI (History of Present Illness): Pain onset was 3 hours prior to admission, described as intense, crushing chest pain, radiating to the jaw and left arm. Associated with nausea and profuse sweating.

ROS (Review of Systems): Reports recent episodes of shortness of breath, especially on exertion. No fever, cough, or abdominal pain.

Hx (History):

• Medical: History of hypertension, high cholesterol. No previous cardiac events.
• Social: Smoker for 30 years, moderate alcohol use.
• Rx (Current Medications): Amlodipine 5mg daily, atorvastatin 20mg daily.
• Allergies: No known drug allergies.

Objective:

• Vital Signs: Blood pressure 150/90 mmHg, heart rate 102 bpm, respiratory rate 22 breaths/min, oxygen saturation 94% on room air.
• Physical Exam: Distressed appearance, diaphoretic, pallor noted. Chest auscultation reveals regular rate and rhythm, no murmurs.
• ECG Findings: ST elevation in leads II, III, and aVF.
• Lab Results: Troponin levels elevated.

Assessment:

• Primary Diagnosis: Acute Inferior Wall Myocardial Infarction.
• Differential Diagnoses: Angina, pericarditis, pulmonary embolism.

Plan:

• Immediate administration of aspirin, nitroglycerin, and morphine for pain relief.
• Start IV heparin infusion.
• Urgent cardiac catheterization planned.
• Admission to the Cardiac Care Unit for close monitoring and further management.