Medical information revisited

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An article about the importance of medical information

04.25 am, a 78 years old man sits on his bed when the prehospital medical emergency team arrives.

He lives alone and on first sight generally seems to be in a good condition. He woke up 30 min. ago with shortness of breath that he first recognized the evening before, but not so bad. He does not really report any further complaints, especially not the ones medical teams always ask for in these situations as they are typical for myocardial infarction (e.g. chest tightness or pain).

He cannot recall any preexisting lung or heart diseases but has not seen a doctor for some time. He states not to take any medication.

Lungs sound normal on auscultation and vital signs (blood pressure, pulse rate and oxygen saturation, skin and body temperature also are normal. Only his breathing rate is slightly higher and his legs appear a little bit swollen.

He reports that during the last days it was harder for him to climb up the stairs to his apartment. An ECG shows a left bundle branch block, a pattern that if it is new and accompanied by typical complaints means that this patient has to be transported to the next heart catheter lab in order to be examined there as soon as possible. However, the symptoms are not 100 % clear in this case.

Therefore, the team wants to know if the ECG pattern was already diagnosed before in order to make the best decision for him.

If diagnosed before, actual complaints could also be rated as signs of a chronic and now aggravating heart disease and there is no need for an immediate intervention. Unfortunately, the man does not know and there are no written medical reports available.

For safety reasons, the medical team decides to treat him under the suspicion of an acute heart attack including a transport to the catheter lab for emergency intervention.

This case report shows that decision making in medicine is not always straight forward but multilayer by combining actual complaints and medical history.
Additional information can be of great help to ensure safe and best medical care.

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