Chest Pain Assessment 1
Chest pain Onset [text] prior to evaluation Onset while: [text] Associated Pain Location: [text] Radiation: [text] Severity now: [text] Duration: [text] Characterized as: [text]. The pain is relieved with [text] [select value="no|YES"] <-- OTC NSAID's [select value="no|YES"] <-- Rest [select value="no|YES"] <-- exertional pain [select value="no|YES"] <-- pleuritic pain The pain is worse with [text] [select value="no|YES"] <-- supine or leaning forward ( concern for pericarditis) [select value="no|YES"] <-- Rest [select value="no|YES"] <-- exertional pain [select value="no|YES"] <-- pleuritic pain Associated Symptoms: [select value="no|YES"] <-- nausea/vomiting [select value="no|YES"] <-- diaphoresis [select value="no|YES"] <-- shortness of breath Pertinent PMH [select value="no|YES"] <-- Coronary Disease [select value="no|YES"] <-- Cerebrovascular disease [select value="no|YES"] <-- Diabetes Mellitus [select value="no|YES"] <-- Peptic Ulcer or GERD [select value="no|YES"] <-- Chest injury or overuse [select value="no|YES"] <-- ETOH use Pt does not have recent prolonged travel, recent trauma, hypercoagulable state, hormonal therapy or hx of blood clots in the family. Cardiovascular risks are reviewed as follows: [select name="Q1" value="no=0|YES=1"] <-- Male 55 years or over/Female 65 or over [select name="Q2" value="no=0|YES=1"] <-- Known CAD or cerebrovascular disease [select name="Q3" value="no=0|YES=1"] <-- Pain not reproducible by palpation [select name="Q4" value="no=0|YES=1"] <-- Pain worse during exercise [select name="Q5" value="no=0|YES=1"] <-- Patient assumes pain is cardiogenic Score --> [calc value="score=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)" memo="score"] out of 5. Interpretation --> [calc value="score=(Q1)+(Q2)+(Q3)+(Q4)+(Q5);score>3?'High (62.7%) risk, proceed with ACS evaluation.':score>1?'Moderate (12.1%) risk, obtain ECG and proceed with ACS or other evaluations as indicated.':'Low (0.6%) risk, if no other indication of cardiac cause, evaluate for non-cardiac causes.'" memo="interpretation"] [checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"] reference: AAFP Point-of-Care Guide at [link url="http://www.aafp.org/afp/poc" memo="Ebell (2011) Am Fam Physician 83: 603-5"][/conditional] Pt denies fever, diaphoresis, rash, palpitations, dyspnea, orthopnea, PND, cough, sputum, hemoptysis, abdominal pain, nausea, vomiting, dysphagia, syncope, lower extremity pain. Differential: Heart/ vascular: Angina MI Acute pericarditis Aortic dissection Lungs: Pneumonia PE Pneumothorax. GI: GERD Peptic ulcer disease Pancreatitis Diffuse esophageal spasm. Other: Costochondritis Rib fracture Anxiety Herpes zoster Skin lacerations Muscle strain. Objective: vitals = all normal Pt in distress - flushed face, gripping chest with hand. No Anemia clinically; No Cyanosis; No Lymphadenopathy; No edema ENT: Ears normal,, Nose & Mouth assessment normal CVS: S1=S2, No S3/4, RRR, no murmurs heard Resp: No distress, GAEB , widespread coarse crackles throughout both lungs, no wheezes DERM: No rash, Normal exam MSK: Lt upper pectoralis major muscle area is tender to deep touch Initial ECG normal 2nd ECG- ST suppression in inferior leads. 3rd ECG- continuous ST depression inferior leads with inverted T vaves Initial troponin measurment- 50-100 positive Rest of initial bloodwork = all normal Assessment: call out ER visit - Non-STEMI (consider Unstable angina over weekend, inferior ischemia today). CC- 19:00 - 20:15 pm Critical care - first 30 min 7:00 - 7:30 pm - 5 min attendance to other pot from 7:20-7:25 pm - continuous ECG monitoring - STEMI protocol Critical care - second 30 min 7:30 - 8:00 - continuous ECG monitoring - STEMI protocol Critical care - third 30 min 8:00 - 8:25 - medical student monitored and I reviewed ECG's and referred pt - continuous ECG monitoring - STEMI protocol Crisis intervension 20 min - discussion with pt and wife - explained condition in detail - discussed treatment now and possible treatment options later, including probable referral to vancouver for angiogram - pt settled after initial anxiety and stress reaction Urgent specialist consult with Internist at UNHBC on call, Dr - he referred to ER physician and agreed with treatment approach Urgent ER physician consult at , Dr = he accepted unconditionally - agreed with treatment, not to give TNK at this time Urgent tel consult with PTN - Dr , RN's and - accepted stat transfer - nurse to accompany pt with transfer Plan: 1) NSTEMI/UA protocol initiated - 325 mg ASA stat po given in ER - Nitro patch 0.4mg SC - Metoprolol 25 mg PO STAT and q12hrs - Clopidegrel 300mg PO STAT - Atorvastatin 80 mg PO STAT - Enocaparin 72mg SC STAT, then qrn - Morphine sulfate 2.5 mg IV q15min prn - Saline lock in place 2) Transfer to
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