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# A&E Attendance — Dr Smith PC/ Chest pain, worse on exertion HPC/ 54 year old male presenting with 2 hour history of central crushing chest pain radiating to the left arm. Associated with nausea and diaphoresis. PMH/ Hypertension, Type 2 diabetes DH/ Metformin 500mg BD, Ramipril 5mg OD ALLG/ NKDA SH/ Non-smoker, occasional alcohol OE/ Alert and oriented, appears uncomfortable CVS/ HS I+II+0, no murmurs, JVP not raised RS/ Air entry equal bilaterally, no added sounds GI/ Abdomen soft, non-tender IMP/ Possible acute coronary syndrome DDX/ GORD, musculoskeletal, PE IX/ 12-lead ECG, troponin, FBC, U&E, CRP PLAN/ Serial ECGs, repeat troponin at 6hrs, aspirin 300mg stat, GTN PRN, cardiology referral
History:
PC/
HPC/
PMH/
DH/
FH/
SH/
ALLG/
Exam:
OE/
RS/
CVS/
CNS/
GI/
MSK/
Assessment:
IMP/
DDX/
IX/
PLAN/
RX/
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