Clinical Notes
Manage and review patient clinical notes
S — Subjective
45-year-old male presenting with chest tightness for the past 2 days. The discomfort is described as a pressure-like sensation, rated 4/10, non-radiating. No associated dyspnoea, palpitations, or diaphoresis. Patient has known hypertension on Amlodipine 5mg OD.
O — Objective
BP: 158/96 mmHg (R arm, seated). HR: 88 bpm, regular. RR: 16/min. SpO2: 98% on room air. Temp: 37.1°C. Chest: Clear to auscultation bilaterally, no added sounds. CVS: S1 S2 normal, no murmurs. Abdomen: Soft, non-tender.
A — Assessment
Uncontrolled hypertension with atypical chest pain. ECG normal. Cardiac enzymes pending. Low probability of ACS based on clinical presentation. Possible musculoskeletal or GERD-related chest pain.
P — Plan
1. ECG ordered — reviewed, sinus rhythm, no ischaemic changes. 2. Troponin I at 0h and 3h — pending. 3. Atorvastatin 20mg OD added to existing regimen. 4. Amlodipine dose escalated to 10mg OD. 5. Dietary counselling provided. Advised low-sodium diet. 6. Review in 1 week with blood reports (lipid profile, RFT, electrolytes). 7. Patient advised to return immediately if chest pain worsens or new symptoms develop.