Scribe BC - ED admission note

Scribe BC - ED admission note Chief Complaint - Presenting Issue: Chest pain. - The patient presents with sudden onset of severe chest pain, radiating to the left arm, associated with shortness of breath and diaphoresis. Past Medical History - Hypertension, Hyperlipidemia. - Appendectomy at age 16. - Medications: Aspirin 81mg daily, Atorvastatin 20mg daily, Lisinopril 10mg daily. - Allergies: NKDA. Social History - Smokes 1 pack of cigarettes per day for 20 years. - Drinks alcohol occasionally, 2-3 units per week. - Denies illicit drug use. - Works as a software engineer. Family History - Father had a history of myocardial infarction at age 60. Physical Examination - Vital Signs: BP 160/90 mmHg, HR 110 bpm, RR 24 breaths/min, Temp 37.0°C, SpO2 94% on room air. - General examination: Appears anxious and in moderate distress. - CVS: Tachycardic, regular rhythm, no murmurs. - Resp: Bilateral crackles in the lower lung fields. - Abdo: Soft, non-tender, bowel sounds present. - MSK: No deformities or limitations. - Neuro: Alert and oriented to person, place, and time. Investigations - Pathology: Troponin elevated, CBC within normal limits, electrolytes WNL. - Imaging: Chest X-ray shows mild pulmonary congestion. ECG shows ST-segment elevation in leads II, III, and aVF. - Other Investigations: None. Assessment - Acute Myocardial Infarction (Inferior wall). - Differential diagnosis: Unstable angina, pulmonary embolism, aortic dissection. Plan/Treatment - Immediate Management: Administered 325mg aspirin, 0.4mg sublingual nitroglycerin, and started on oxygen. IV access established. - Investigations: Cardiac catheterization planned. - Referrals: Cardiology consult requested. - Discharge & Follow-up Instructions: Patient to be admitted to the cardiac care unit. Follow-up with cardiologist scheduled within one week. Emergency "The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks."