Medical Case Summary Sheet
Patient Information
Patient Name: Malcolm Raynor
Age: 45 years
Gender: Male
Medical Record Number: 12345678
Contact Information: 222 555 7777
Chief Complaint
The patient presented with persistent chest pain radiating to the left arm, accompanied by shortness of breath and dizziness. Symptoms began approximately seven hours prior to admission.
History of Present Illness
The patient reports a gradual onset of dull, intermittent chest pain over the past week, which acutely worsened in intensity today. The pain is accompanied by nausea and diaphoresis. No significant relieving or exacerbating factors have been identified.
Past Medical History
Hypertension – diagnosed 10 years ago
Type 2 Diabetes Mellitus – diagnosed 5 years ago
Hyperlipidemia – managed with atorvastatin
Medications
Allergies
Physical Examination
The examination reveals an overweight male in mild distress. Vital signs: BP 150/90 mmHg, HR 95 bpm, RR 22 breaths/min, Temp 98.6°F, Oxygen saturation 95% on room air.
Cardiovascular: S1 and S2 are present, no murmurs, gallops, or rubs noted
Respiratory: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended
Extremities: No edema, pulses equal bilaterally
Investigations
Test | Date | Result | Normal Range |
|---|
ECG | 2053-10-25 | ST-segment elevation in leads II, III, and aVF | - |
Troponin I | 2053-10-25 | 2.5 ng/mL | < 0.04 ng/mL |
Complete Blood Count (CBC) | 2053-10-25 | Within normal limits | - |
Comprehensive Metabolic Panel (CMP) | 2053-10-25 | Within normal limits | - |
Assessment
The patient's presentation is consistent with an acute ST-elevation myocardial infarction (STEMI) primarily affecting the inferior wall of the heart, evidenced by ECG changes and elevated cardiac biomarkers.
Plan
Immediate cardiac catheterization for revascularization
Continue aspirin and initiate high-dose statin therapy
Administer beta-blocker to control heart rate and blood pressure
Pain management with intravenous morphine as needed
Consult cardiac rehabilitation for post-discharge planning
Follow-up
Schedule a follow-up appointment with a cardiologist within one week of discharge. Reinforce lifestyle modifications, including dietary changes and physical activity, to prevent recurrent cardiac events.
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