Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute onset of substernal chest pressure radiating to the left shoulder and jaw, associated with diaphoresis, nausea, and dyspnea. Symptoms began [Time] ago, described as [Quality: crushing/tightness], intensity [Scale 1-10]. No prior history of similar episodes. Symptoms are constant, non-pleuritic, and unresponsive to sublingual nitroglycerin.
Clinical Examination Findings
Patient appears in acute distress, diaphoretic, and pale. Vitals: BP [Value], HR [Value], O2 sat [Value]. Cardiovascular: Tachycardic, regular rhythm, S1/S2 present, no murmurs, rubs, or gallops. Lungs: Bilateral clear to auscultation, no crackles or wheezing. Extremities: No peripheral edema, pulses 2+ bilaterally. Neurological: Alert and oriented x3, no focal deficits.
Treatment Protocol
Immediate activation of Cardiac Catheterization Lab for primary PCI. Administered Aspirin 325mg (chewed), P2Y12 inhibitor (e.g., Ticagrelor 180mg), and weight-based Heparin bolus. Initiated high-intensity statin therapy and IV nitroglycerin for pain control. Monitoring for arrhythmias; prepared for potential hemodynamic support if cardiogenic shock develops.