Hospitalist Inpatient Admission Template

Chief Complaint: The patient presents with a three-day history of worsening shortness of breath and chest pain. History of Presenting Illness: The patient, a 68-year-old male, reports the onset of shortness of breath three days ago, which has progressively worsened. He also describes a sharp, stabbing chest pain that radiates to his left arm. The pain is exacerbated by deep breathing and movement. He denies any recent travel or sick contacts. He reports a history of similar episodes in the past, but this is the most severe. Detailed history of investigations and findings performed in the emergency department or transferring facility: The patient was evaluated in the emergency department, where an ECG showed ST-segment elevation in leads II, III, and aVF, suggestive of an inferior myocardial infarction. Cardiac enzymes, including troponin, were elevated. A chest X-ray revealed mild pulmonary congestion. The patient received aspirin, oxygen, and intravenous fluids in the ED. Past Medical History: Hypertension, Hyperlipidemia, Coronary Artery Disease, Type 2 Diabetes. Home Medications: Aspirin 81mg daily, Metoprolol 25mg twice daily, Lisinopril 10mg daily, Atorvastatin 20mg daily, Metformin 500mg twice daily. Allergies: NKDA. Social History: The patient is a former smoker, having quit 10 years ago. He drinks alcohol occasionally. He is married and lives with his wife. Family History: Father had a history of myocardial infarction at age 60. Review of Systems: Constitutional symptoms: Reports fatigue. Eyes: Denies any visual changes. Ears, Nose, Mouth, Throat: Denies any sore throat, nasal congestion, or ear pain. Cardiovascular: Reports chest pain and palpitations. Respiratory: Reports shortness of breath and cough. Gastrointestinal: Reports nausea. Genitourinary: Denies any urinary symptoms. Musculoskeletal: Denies any musculoskeletal pain. Integumentary (Skin): Denies any skin rashes or lesions. Neurological: Denies any headache or dizziness. Psychiatric: Denies any symptoms of depression or anxiety. Endocrine: Denies any symptoms of polyuria or polydipsia. Hematologic/Lymphatic: Denies any bleeding or bruising. Allergic/Immunologic: Denies any allergic reactions. Physical Exam: Vitals: BP 140/90, HR 100, RR 24, Temp 37.0°C, SpO2 92% on room air. Abdominal examination: Soft, non-tender, no guarding. Lab Results: Troponin I elevated at 3.5 ng/mL. Imaging Results: Chest X-ray shows mild pulmonary congestion. Assessment/Plan: 1. Acute Myocardial Infarction - Impression: Inferior myocardial infarction. - Differential diagnosis: Unstable angina, pulmonary embolism. - Investigations planned: Serial cardiac enzymes, repeat ECG, cardiology consultation, possible cardiac catheterization. - Treatment planned: Continue aspirin, metoprolol, lisinopril, and atorvastatin. Administer oxygen, intravenous fluids, and consider heparin drip. Cardiology consult. - Relevant referrals: Cardiology. Two Midnight Documentation: The patient is expected to require at least two midnights of hospitalisation due to the severity of the acute myocardial infarction and the need for further cardiac evaluation and management. Total time spent: 45 minutes.