Protected Document: █ █ █ B-10070 █ █ █
Intake Date: - - -
Intake Time: 13:00
Patient Name: Ezra Dune
[Intake doctor: J-QAR]
Medical Call - Patient Walk-in
Doctor: Julian Qar
Medical Assistant: Hazel
Neuro Med: C. Trevino
Chest pain, difficulty breathing, nausea
|Treatment||ACE inhibitors, Beta Blockers, Rest, Stress relief activities|
[Neuro Med: C-Trevino]
The patient walked into med bay ED complaining of chest discomfort, difficulty breathing, nausea, and vomiting.
Patient physical tests and blood work came back unremarkable.
Unfortunately due to left arm augmentation, we opted for a central line due to the severity of the cardiac injury and patient age.
The patient was kept in the med bay for a 24 hour monitoring period to ensure that chest pain had not increased once ACE inhibitors and beta-blockers were administered.
The use of thinning medication was not needed.
Neuro med dispatched to discuss stress relief activities with Mr. Dune. The patient was compliant for the most part though at one point became agitated when asked to discuss his past and the reason for the increase in stress.
No change in the overall size of LV base when evaluated through Ultrasonic Echo. Medication and rest helped with the chest pain and nausea.
As long as Mr. Dune keeps up with the treatment plan he should make a full recovery with no further damage to cardiac muscles or surrounding tissues.
Cardiac enzymes test:
Chest & Abdomen:
No exterior trauma to chest or abdomen. No tenderness.
Coronary angiogram performed, signs of left ventricular enlargement. The apex of the left ventricle exhibits tightening whereas the base shows signs of temporary enlargement.
[Suggested diagnosis: TCM [ Takotsubo cardiomyopathy ] Stress-induced cardiomyopathy.]
No major complaints besides heavy stress, the onset of anxiety, and difficulty sleeping at night. The patient declined a sleep aid and anti-anxiety prescription.
For the next three weeks, the patient should limit any stressful activities and the intake of stressful information. Strenuous exercise is prohibited at this time until a follow-up appointment is scheduled.
Retesting requirements: Clear EKG, Ultrasonic Echo Reading, Coronary angiogram. If chest pain persists and is increased in severity, with dizziness, slurred speech, the patient should call the ED line for an immediate medical transport unit.
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