Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Chest pain (may be crushing, pressure, burning, or radiating to jaw/shoulder/arm)
Discomfort (may be atypical presentation, especially in women or diabetics)
Shortness of breath
Nausea/vomiting
Diaphoresis (sweating)
History of Present Illness:
Onset, duration, severity, and character of chest pain.
Associated symptoms (shortness of breath, nausea, diaphoresis).
Risk factors for coronary artery disease (CAD)
Hypertension
Diabetes mellitus
Hyperlipidemia
Smoking history
Family history of CAD
Prior episodes of chest pain or angina.
Past Medical History:
Underlying medical conditions (e.g., hypertension, diabetes, hyperlipidemia).
Prior cardiac surgeries (e.g., coronary artery bypass graft (CABG)).
Social History:
Smoking history (current or former)
Diet and exercise habits
Stress level
Physical Exam:
General examination: Assess vital signs (blood pressure, heart rate,
oxygen saturation), look for signs of heart failure (jugular venous distention,
peripheral edema) or shock.
Cardiovascular examination: Listen for heart murmurs suggestive of
valvular disease.
Laboratory Tests:
Cardiac biomarkers: Serial troponin levels are crucial for diagnosis.
Rising or elevated troponin is indicative of myocardial injury.
Complete blood count (CBC): May show mild leukocytosis (increased
white blood cells) in response to inflammation.
Basic metabolic panel (BMP): To assess electrolyte balance and
kidney function.
Lipid panel: To evaluate cholesterol levels and cardiovascular risk.
Electrocardiogram (ECG):
May show changes suggestive of ischemia (lack of oxygen to the heart muscle)
but not necessarily ST-segment elevation (unlike STEMI). Serial ECGs may be
needed to monitor for changes.
Cardiac Imaging:
Chest X-ray: May be normal but can help rule out other conditions
(e.g., pneumonia).
Echocardiogram: To assess heart function, chamber size, and presence of
wall motion abnormalities suggestive of infarction.
Risk Stratification:
Based on clinical presentation, cardiac biomarkers, and ECG findings,
patients with NSTEMI can be categorized into high-risk, intermediate-risk,
or low-risk categories. This guides treatment decisions and prognosis.
Assessment:
Non-ST-elevation myocardial infarction (NSTEMI): Diagnosed based on
clinical presentation, elevated cardiac biomarkers, and ECG changes suggestive
of ischemia.
Risk stratification: Patient categorized as high-risk,
intermediate-risk, or low-risk based on clinical assessment.
Differential Diagnoses:
Consider other causes of chest pain:
Stable angina pectoris
Pericarditis
Esophageal spasm
Musculoskeletal pain
Plan:
The treatment plan for NSTEMI aims to prevent further myocardial injury,
improve symptoms, and reduce the risk of future events. Possible elements
include:
Medications:
Antiplatelet therapy (aspirin, P2Y12 inhibitors) to prevent blood
clots.
Antianginal medications (nitrates, beta-blockers, calcium channel
blockers) to improve blood flow to the heart and relieve chest pain.
Statins to lower cholesterol levels.
Revascularization: Procedures to open blocked coronary arteries
may be indicated, such as percutaneous coronary intervention (PCI)
with stenting or coronary artery bypass graft (CABG) surgery. The choice
depends on various factors including coronary anatomy and risk profile.
Lifestyle modifications: Smoking cessation, dietary changes, and
regular exercise are crucial for long-term management and prevention
of future events.