Presenting History
60 year old male
4 hours central chest pain no radiation
Pale & sweaty
Orthopnea √ PND √
↑breathlessness ↑ lethargy for past 2 weeks
BP 90/50 Pulse 110 (reg) RR 26 02 Saturations: Sa02 % 82%
Heart Sounds 1 2 murmur
Crackles in both bases of lungs >
Past Medical History
Myocardial Infarction- Anterior- 2005
Hypercholestraemia
Mild COPD
Alcohol 5-10 units weekly
Medication
Atenolol: 50mg twice daily
Ramipril: 5mg twice daily
Spironolactone: 25mg daily
Aspirin: 75mg daily
Isosorbide Mononitrate: 20mg twice a day
Simvastatin: 40mg daily at night
Tiotropium inhaler
GTN Spray
No Known Allergies
Working diagnosis
Acute Heart Failure (HF) secondary to Acute Coronary Syndrome (ACS).
Learn more about ACS in module 4.
Plan
12 lead ECG sinus rhythm with left bundle branch block (QRS > 150 ms) no acute changes. Signs of previous MI.
Monitored bed
Chest Xray (CXR)
Bloods:
- Troponin
- U&Es
- LFTs
- Full Blood Count
- Cholesterol
- Glucose
- CRP Echocardiogram thereafter
Dr Jones (signature) SHRO
Page last reviewed: 28 Jul 2020
