GIM Ward Round Template

Ward Round By: Dr John Smith on 08/06/2024

Patient Demographic Information: A 67-year-old female

Social History: Lives alone in her own home; daughter visits daily. Mobilises independently indoors using a walking stick; outdoors with assistance.

PMH: Type 2 diabetes mellitus, hypertension, hyperlipidaemia, osteoarthritis (knees), previous cholecystectomy

Drug History: Metformin 500 mg PO BID, amlodipine 10 mg PO OD, atorvastatin 20 mg PO OD, paracetamol 1 g PO QID as required

PC: Admitted with sudden onset chest pain and shortness of breath for 4 hours

Current Active Issues:

1. Acute coronary syndrome: On aspirin 75 mg PO OD and clopidogrel 75 mg PO OD. Awaiting further cardiology assessment.
2. Type 2 diabetes: Blood glucose monitored; no hypoglycaemia episodes.
3. Hypertension: BP controlled.
4. Oxygen therapy: Receiving 2 L/min via nasal cannula; saturations maintained.
5. Pain management: Chest pain well controlled with paracetamol.

Observations & Vital Signs: EWS: 1 HR: 84 bpm Temp: 36.7 °C BP: 132/78 mmHg Oxygen sats: 96 % on 2 L/min nasal cannula Respiratory rate: 18 /min

Results:

• Troponin I: 0.23 ng/mL (elevated)
• ECG: ST depression in lateral leads
• Chest X-ray: Clear lung fields, no consolidation
• FBC: Hb 132 g/L, WCC 7.4 × 10⁹/L, Plt 240 × 10⁹/L
• U&E: Na 139 mmol/L, K 4.4 mmol/L, urea 4.9 mmol/L, creatinine 77 µmol/L

Examination: Alert, comfortable at rest. No distress. Heart sounds normal, no murmurs. Chest clear, no crackles or wheeze. Abdomen soft, non-tender. Limbs warm, no oedema.

Impression: Acute coronary syndrome with good initial response to therapy. Haemodynamically stable. No signs of heart failure or other complications identified.

Management Plan:

• Continue dual antiplatelet therapy
• Cardiology to review; consider transfer for angiography
• Maintain oxygen therapy as needed
• Monitor cardiac enzymes and ECG
• Blood glucose monitoring; continue diabetes treatment
• Review pain control regularly
• Encourage gentle mobilisation with assistance
• Daily bloods and repeat ECG tomorrow