❤️ Vitals — Latest (14:23)
Blood Pressure88/60 mmHg
Heart Rate112 bpm
O2 Saturation91%
Temperature98.6°F
Respiratory Rate24 /min
Pain Scale8/10 — Chest
GCS15
🩺 Active Problems
Acute STEMI (I21.19)Active — Today
Hypertension (I10)Chronic
Type 2 Diabetes (E11.9)Chronic
Hyperlipidemia (E78.5)Chronic
Obesity (E66.01)BMI 33.2
📝 Active Orders
| Order | Type | Priority | Status | Ordered |
|---|---|---|---|---|
| Aspirin 325mg PO x1 | Medication | STAT | Administered | 14:10 |
| Heparin 60 units/kg IV bolus | Medication | STAT | Infusing | 14:12 |
| Troponin I, Serial q3h | Lab | STAT | 1st result pending | 14:15 |
| 12-Lead ECG — repeat in 30 min | Diagnostic | STAT | Scheduled 14:45 | 14:15 |
| CBC, CMP, Coag Panel | Lab | STAT | Collected | 14:10 |
| NS 500mL IV bolus | Medication | STAT | Infusing | 14:08 |
| Cardiology Consult — Transfer | Consult | STAT | Awaiting transfer | 14:20 |
📄 Recent Notes
67-year-old male presenting with acute onset crushing substernal chest pain radiating to left arm, diaphoresis, and nausea beginning ~45 minutes prior to arrival. 12-lead ECG shows ST elevation in leads II, III, aVF consistent with inferior STEMI. Patient hemodynamically unstable with BP 88/60. Aspirin and heparin bolus administered. — does not have PCI capability. Initiating emergent transfer to facility with cardiac catheterization lab. Door-to-balloon time critical.
Patient arrived via personal vehicle. Alert and oriented x3, in acute distress. Chest pain 8/10. IV access established x2 (18g R AC, 20g L hand). Cardiac monitor applied — sinus tachycardia, no ectopy. O2 via NC at 4L/min applied. Dr. Mitchell notified immediately.