Initial consideration in this patient included myocardial infarction
with and without ST segment elevation (STEMI, NSTEMI), aortic dissection,
aortic aneurysm, pulmonary embolism (PE), pericarditis, myocarditis, coronary
artery spasm, cardiac contusion, and pneumothorax among others.
Patient presented with complaint of [chest pain/dyspnea/fatigue] with
EKG obtained [on arrival in the ED/in the field] showing no evidence of ST
elevations [and/but ST segment depressions in leads ##/V#-V# concerning for anterior/lateral/inferior
ischemia]. Initial labs obtained to
include a troponin [additional labs] and notable for [elevated
troponin/etc.]. Aortic dissection
considered to be unlikely in patient without [radiation of pain to back,
tearing quality of pain, maximal pain at onset, pulse deficit, associated
neurologic symptoms, mediastinal widening on chest x-ray] or other suggestive
findings.
Dr. [Name] of Cardiology consulted [and evaluated the patient at the
bedside/reviewed the EKG and history] and agreed with diagnosis of NSTEMI. Patient received Aspirin [162/324] mg in the
[field/ED]. Patient treated with
[Nitroglycerine/Morphine] with improvement noted in [chest pain/dyspnea]. Anticoagulation initiated in the ED with [Heparin/Lovenox
after discussion with Cardiology].
We discussed admission to [CCU/ICU/catheterization lab] with Dr. [Name]
of Cardiology for NSTEMI [with/without high risk features]. We discussed concern for NSTEMI and plan for
transfer for [admission to CCU/ICU with plan for initiation of
anticoagulation/transfer to cardiac catheterization lab for percutaneous
intervention (PCI)] with associated risk and benefits, and the patient
demonstrated understanding and agreement.
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