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, constant in nature, 8/10 intensity, unrelieved by rest or sublingual nitroglycerin. No prior history of similar episodes.
Clinical Examination Findings
Patient appears in acute distress, diaphoretic, and tachypneic. Vitals: BP [Value], HR [Value], O2 sat [Value] on RA. Cardiac exam: Tachycardic, regular rhythm, no murmurs, rubs, or gallops. Pulmonary exam: Bilateral crackles at bases. Extremities: No peripheral edema, pulses 2+ bilaterally.
Treatment Protocol
Immediate activation of Cardiac Catheterization Lab for primary PCI. Administered Aspirin 325mg, P2Y12 inhibitor (Ticagrelor/Clopidogrel), and Heparin bolus. Initiated high-intensity statin and IV Nitroglycerin titration. Monitoring for arrhythmias and hemodynamic instability.