Free Medical Case Summary Sheet Template
Medical Case Summary Sheet
Patient Information
Patient Name: Malcolm Raynor
Age: 45 years
Gender: Male
Medical Record Number: 12345678
Contact Information: 222 555 7777
Chief Complaint
The patient presented with persistent chest pain radiating to the left arm, accompanied by shortness of breath and dizziness. Symptoms began approximately seven hours prior to admission.
History of Present Illness
The patient reports a gradual onset of dull, intermittent chest pain over the past week, which acutely worsened in intensity today. The pain is accompanied by nausea and diaphoresis. No significant relieving or exacerbating factors have been identified.
Past Medical History
-
Hypertension – diagnosed 10 years ago
-
Type 2 Diabetes Mellitus – diagnosed 5 years ago
-
Hyperlipidemia – managed with atorvastatin
Medications
-
Lisinopril 20 mg daily
-
Metformin 500 mg twice daily
-
Atorvastatin 20 mg nightly
-
Aspirin 81 mg daily
Allergies
-
No known drug allergies
Physical Examination
The examination reveals an overweight male in mild distress. Vital signs: BP 150/90 mmHg, HR 95 bpm, RR 22 breaths/min, Temp 98.6°F, Oxygen saturation 95% on room air.
-
Cardiovascular: S1 and S2 are present, no murmurs, gallops, or rubs noted
-
Respiratory: Clear to auscultation bilaterally
-
Abdomen: Soft, non-tender, non-distended
-
Extremities: No edema, pulses equal bilaterally
Investigations
|
Test |
Date |
Result |
Normal Range |
|---|---|---|---|
|
ECG |
2053-10-25 |
ST-segment elevation in leads II, III, and aVF |
- |
|
Troponin I |
2053-10-25 |
2.5 ng/mL |
< 0.04 ng/mL |
|
Complete Blood Count (CBC) |
2053-10-25 |
Within normal limits |
- |
|
Comprehensive Metabolic Panel (CMP) |
2053-10-25 |
Within normal limits |
- |
Assessment
The patient's presentation is consistent with an acute ST-elevation myocardial infarction (STEMI) primarily affecting the inferior wall of the heart, evidenced by ECG changes and elevated cardiac biomarkers.
Plan
-
Immediate cardiac catheterization for revascularization
-
Continue aspirin and initiate high-dose statin therapy
-
Administer beta-blocker to control heart rate and blood pressure
-
Pain management with intravenous morphine as needed
-
Consult cardiac rehabilitation for post-discharge planning
Follow-up
Schedule a follow-up appointment with a cardiologist within one week of discharge. Reinforce lifestyle modifications, including dietary changes and physical activity, to prevent recurrent cardiac events.
