PC: Shortness of breath and pleuritic chest pain

HPC: [Paramedic Note] Conveyed via ambulance following acute onset of left-sided pleuritic chest pain and breathlessness starting 2 hours prior to arrival. [relevant history of presenting complaint] Pain is sharp, 7/10 in severity, exacerbated by deep inspiration. Associated with mild diaphoresis. No syncope or palpitations. [specific symptoms] Dyspnoea at rest, worsening on exertion.

[pertinent negatives] No lower limb swelling, pain, or calf tenderness. No recent long-haul travel or surgery.

PMH: Asthma, hypertension

[Current medications] salbutamol 100 mcg MDI PRN, amlodipine 5 mg PO OD

[Allergies] Penicillin (causes rash)

Social History: [Patient currently lives with] Lives with spouse in a first-floor flat [Carers present or not] Independent with ADLs, no carers [Profession] Retired accountant [Exercise Tolerance] Usually walks 30 minutes daily, currently limited to short distances due to dyspnoea [Alcohol] 6 units per week [Smoking] Ex-smoker, 15 pack-years, quit 10 years ago [Recreational Drug use] Nil

Vitals: HR 105 bpm, BP 128/82 mmHg, RR 24 breaths/min, SpO2 94% on air, Temp 36.8 °C

O/E: [Chaperone Present or not] Chaperone present (Staff Nurse Davies)

General appearance: Alert, mildly tachypnoeic, no acute respiratory distress at rest

Cardiovascular: Tachycardic, dual rhythm, no murmurs or added sounds

Respiratory: Decreased air entry at left lung base, clear to percussion elsewhere, no wheeze

Abdominal: Soft, non-tender, non-distended, bowel sounds present

Neurological: GCS 15/15, cranial nerves intact, no focal neurological deficit

Musculoskeletal: No chest wall tenderness to palpation

Investigations: ECG shows sinus tachycardia at 102 bpm with S1Q3T3 pattern. Arterial blood gas on air: pH 7.46, pCO2 4.1 kPa, pO2 9.2 kPa. D-dimer elevated at 1.8 mg/L FEU. Chest radiograph clear bilaterally with no focal consolidation or pneumothorax.

Impression: [summary of clinical impression] Suspected pulmonary embolism given pleuritic chest pain, tachypnoea, tachycardia, and ECG findings, in a low-to-moderate risk patient. [red flags or concerns] Potential for haemodynamic instability if massive PE.

Plan:

• [treatment plan] Commenced on low molecular weight heparin (enoxaparin 1.5 mg/kg SC OD) pending imaging.
• [investigations ordered] Computed tomography pulmonary angiogram (CTPA) requested.
• [follow-up plan] Review by the acute medical team following CTPA results.
• [discussion with patient/family and agreed plan] Discussed suspected diagnosis and need for CT scan with patient and spouse; consent obtained.
• [safety-net advice] Advised to press call bell immediately if worsening breathlessness, dizziness, or chest pain occurs.