Werribee Date: 16 NOV 2022 Tlme:13:25 1

Anival 21

MRN:2751572 DOB:30 OCT 1950 Gender: F Dlscharge Date:14 NOV 2022 16:45
Data 13 NOV2022 to 16 NOV2022
Date StEff Member Note Type
Clinicat Note
13 NOV 2A22 22:10 DR CAO, Jl MED

72 year old lady presented with chest pain

Overseas visitor
Coronary artery stent inserted last year in lndonesia
patient tiaO COVTO early this year, complicated with myocardia infarction, but recovered well
Onset of chest pain this evening - 7pm
Left side chest tightness
Radiated to left arm - neavineii in'hature
No dizzy, fainting, sob, or diaphoresis
Came to ED with her daughter
PH: ICH - stents/AMl, COVID, DtM, HTN
Meds: to be confirmed
SH:
O/E: notdistressed, afebrile, HR 100, RR 18, O2sat99%, BP 120/66
HEENT: nad
Chest: regular rhythm, dual sounds, lungs clear
Limbs: no swelling or tender to lower limbs
ECG: SR, ST depression in lateral leads, no previous ECG to compare with
Al chest pain with ECG changes (new?)
Pj monitciring, pain relief with nreds, repeat ECG in 30 minutes, path - serialTNl, CXR, and review - referral if
necessary
14 NOV 2022 00:31 RN RELIEVING... NIJRSE

A-patent own ainruay

B- spon rr 22 spoZ 97
C bp 113 systolic. Monitored in sinus rythm. HR 84 BPM
D piesented with sudden onset of central radiating chest pain with previous Hx stents and Ml. Pain free on
transfer to cubicle 4. Remains Pain free thus far. Meds administered as charted. Daughter remains with patient as
translator. For rpt trop at 1.30 am

Sarah Leach CRN

14 NOV 2O22 02.13 KIM, JESSIE NURSE

rpt ECG and trop done

ECG checked by Dr. Cao
14 NOV 2022 02:59 RN RELIEVING,.., NURSE

A own patent airway

B spon RR 22 Spo2 96-98 per cent on room air.
C hiormotensive. Regular radial pulse. tvlonitored on telemetry in Sinus rythm, Denies chest pain. Denies
shortness of breath.
D Nil CP or SOB. Pain free since arrived in cubicle 4. Mobilised to toilet with supervision. Voiding without
difficulty. GCS 15 Alert and orientated, PEARL. Daughter remains in attendance and is translating for mother
second troponin taken at 0200

sarah leach CRN

14 NOV 20?2 03:04 DR CAO, Jl MED

CXR: NAD
Pathology: TNI 26 - 89, normal FBE and biochem

Clinically, patient is painfree with stable vital signs

Plan:
add meds as per chart - Ticagrelor 90m9, Atorvastatin 80m9, and Clexane 50mg
cardiac monitoring
discussing with cardiologist in am
14 NOV 2022 O3:09 DR CAO, Jl MED

Added:
patient had positive RAT last Sunday, after arrival in Australia
commenced on Lagivrio for 5 days, and currently is asymptomatic
14 NOV 2022 M.$ DR CAO, JI MED

@ DXC Technology

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