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.
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