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Discipline

: Emergency

Sub Discipline

: Emergency

Document Title

: ETD Chest Pain Clerking Note

Chief Complaints

HISTORY

Onset Of Worst / Continuous Chest Pain

Duration Of Worst / Continuous Chest Pain

Character Of Chest Pain

Burning

Constricting/Pressing

Continuous Pain

Intermittent Pain

Pain at Rest

Pain on Exertion

Pain on Movement/Changing Position

Pain worsen on Exertion

Pleuritic Chest Pain

Pricking/Stabbing

Radiating Pain

Others, specify

Pain Relief

By Rest

By Medication

By Position

Others, specify

Associated Symptoms

Sweating

Nausea

Vomiting

Palpitation

Cough

Fever

Dizziness

Syncopal Attack

Others, specify

Risk Factor

IHD /CAD

Duration

Hypertension

Duration

Diabetes Mellitus

Duration

Dyslipidemia

Duration

Smoker

Cigarette Amount

Ex-Smoker

Duration Of Smoking

Overweight

Bmi

Family History of IHD

Relationship

Others, specify

Common Textbox

Past Medical/Surgical History

Hypertension

Ischemic Heart Disease (IHD)

Diabetes Mellitus

Cerebro Vascular Accident (CVA)

Asthma

COAD

Renal disease

Epilepsy

Peptic Ulcer Disease

Angioplasty

CABG

Previous Operation/Procedure

Others, specify

Drugs History

Personal And Family History

Menstrual History

Menarche Age

years old

LMP

Unsure Of Date

POA

Weeks

Pregnant

YesNo

Menopause Age

years old

Remarks

PHYSICAL EXAMINATION - CHEST PAIN

General Condition

GoodFairPoorMoribund

Hydration Status

NormalMildly dehydratedModerately dehydratedSeverely dehydrated

Peripherals

Pink

Pale

Cyanosed

Jaundice

Cold

Cold and clammy

Warm

Evidence Of Failure

Raised JVP

Peripheral Oedema

Neck Vein

DistendedFlat

Vital Signs & Other Observations

Pupils

Please Update Method

Cardiovascular System (CVS)

Apex Beat

Heave

Thrill

Heart Sound

Murmur

Radial Delay

Radial Remoral Delay

Cns

Lethargy

Restlessness

Mental Status

Neck Stiffness

Cranial Nerve

Peripheral Nerve

Cerebellar

Abdomen

Inspection

Palpation

Auscultation

Bowel Sound

ActiveHyperactiveSluggishAbsent

Respiratory

Tracheal Deviation

Auscultation

NormalAbnormal

Percussion

NormalAbnormal

Skin And Lymph Node

NormalAbnormal

Unilateral Leg Swelling

YesNo

Genitourinary

NormalAbnormal

INVESTIGATION

ECG Finding

Classification of ECG Abnormalities

Type Of Abnormalities

ST elevation >= 0.5 mm

ST elevation >= 1 mm

ST elevation >= 1.5 mm

ST elevation >= 2 mm

ST elevation >= 2.5 mm

ST depression >= 0.5 mm

T-wave inversion >= Inversion 1 mm

Others, specify

Location Of Abnormalities

Inferior: II, III, aVF

Anterior: V1 to V4

Lateral: I, aVL, V5, V6

True posterior : V1 V2

RV: V4R

Anteroseptal: V1 - V3

None

Not stated or described

Extensive ant: V1 - V6

Others, specify

Other ECG Abnormalities

Bed Side Echocardiography

TIMI Risk Score

STEMI

Kilip Score

DIAGNOSIS

Diagnosis

MANAGEMENT

Plan

Orders

Others

Referral

REPERFUSION THERAPY / MANAGEMENT

Contraindication For Reperfusion Strategy

Thrombolysis

Absolute Contraindication

History of intracranial bleed

History of ischemic stroke within 3 months

Active bleeding or bleeding diathesis (Except Menses)

Suspected aortic aneurysm

Known intracranial neoplasm

Known structural cerebral vascular lesion (eg Intracranial AVM)

Significant head trauma within 3 months

No Contraindication

Relative Contraindication

Hypertensive emergency (BP > 180/110mmHg)

History of ischemic stroke more than 3 months

Current Anticoagulant use (INR > 2.0 - 3.0)

Prolonged CPR (>10 minutes)

Major Surgery (in last 3 weeks)

Non compressible vascular venepuncture

Recent internal bleeding (in the last 4 weeks)

Streptokinase given within 5 days to 1 year

Others, specify

Primary PCI

Contraindication

Mechanical failure e.g. Valve rupture

Not consented for PCI(verbal)

Poor social support-vagabond/IVDU

Systolic BP < 80 mmHg

On > than 2 inotropes

CPR > than 5 minutes

Poor EF by eyeballing bedside echo

Age > 75 years

Multiple co-morbids-ESRF/stroke/malignancy

No Contraindication

Choice Of Reperfusion

Common Textbox

EMERGENCY DEPARTMENT TO BE COMPLETED BY HUB

Arrival Blood Pressure

Intubated On Arrival

YesNo

Inotropic Support

SingleDouble> 2

Attempted Cpr

YesNo

Cpr Duration

Case Discussed Prior To

YesNo

CATH LAB TO BE COMPLETED BY HUB

Kilip Score

Cpr On Table

YesNo

Cpr Duration

Comments

Intubated On Arrival

YesNo

Additional Advise

SingleDouble> 2

Any Delay in Door To Balloon time in ( > 120 mins )

YesNo

Reason

Admin Issue

Patient Consent

Unstable Patient

Transportation Issues

Equipment Issues

Others, please specify

SIGNATURES

Notes Component

HISTORY
PHYSICAL EXAMINATION - CHEST PAIN
INVESTIGATION
DIAGNOSIS
MANAGEMENT
REPERFUSION THERAPY / MANAGEMENT
EMERGENCY DEPARTMENT TO BE COMPLETED BY HUB
CATH LAB TO BE COMPLETED BY HUB
SIGNATURES

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