Emergency Room Note
Patient Name: Jarvis White
MRN: 123456
Date: October 8, 2050
Time: 14:30
Attending Physician: Dr. [Your Name]
Chief Complaint:
Chest pain for 30 minutes.
History of Present Illness:
Mr. White is a 55-year-old male who presents to the emergency department with complaints of acute chest pain that started approximately 30 minutes before arrival. The pain is described as a pressure sensation in the center of the chest, radiating to the left arm. He reports associated symptoms of shortness of breath and diaphoresis. The patient denies any nausea, vomiting, or recent trauma.
Past Medical History:
Medications:
Allergies:
No known drug allergies.
Social History:
Family History:
Review of Systems:
Cardiovascular: Chest pain, palpitations
Respiratory: Shortness of breath
Gastrointestinal: No nausea or vomiting
Neurological: No dizziness or headache
Physical Examination:
Vital Signs:
BP: 150/90 mmHg
HR: 98 bpm
RR: 20 breaths/min
Temp: 98.6°F
O2 Sat: 95% on room air
General: Alert, in mild distress due to pain.
Cardiovascular: Regular rate and rhythm, no murmurs.
Respiratory: Clear to auscultation bilaterally.
Gastrointestinal: Soft, non-tender, no distension.
Neurological: Alert and oriented, no focal deficits.
Laboratory and Imaging:
CBC: within normal limits
CMP: within normal limits
Troponin: pending
ECG: ST-segment elevation in leads II, III, and aVF.
Assessment:
Acute coronary syndrome (ACS) – possible ST-Elevation Myocardial Infarction (STEMI)
Hypertension
Diabetes Mellitus
Plan:
Administer aspirin 325 mg chewed
Administer nitroglycerin sublingual for chest pain
Initiate heparin drip
Consult cardiology for cardiac catheterization
Monitor vitals and repeat ECG in 30 minutes
Educate the patient regarding his condition and treatment plan
Disposition:
The patient will be admitted to the telemetry unit for further monitoring and management.
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