Emergency Medicine Specialist
LMR
1 November 2024
The patient, [insert age], presented to the emergency department with complaints of sudden onset chest pain and shortness of breath. The patient's medical history is significant for hypertension and a previous myocardial infarction, as reported by the patient.
Physical examination revealed an elevated heart rate of 110 beats per minute, blood pressure of 160/90 mmHg, and oxygen saturation of 92% on room air. Auscultation of the lungs revealed diminished breath sounds in the left lower lobe. An electrocardiogram (ECG) showed ST-segment elevation in leads II, III, and aVF. Initial troponin levels were elevated.
Differential diagnoses considered included acute myocardial infarction, pulmonary embolism, and aortic dissection. Based on the ECG findings, elevated troponin levels, and the patient's history, the most likely diagnosis is acute myocardial infarction.
ICD-10 code: I21.9 - Acute myocardial infarction, unspecified.
(Create a note about the transcribed visit. It should NOT be in "bullet points" form but rather a "story" told. Use only proper Polish medical nomenclature, don't use colloquial terms such as "noga" for "leg"—instead use "kończyna dolna." When trying to give general conclusions, always phrase tentatively, e.g.: "...is consistent with..." or "...suggests...")
(If there are crucial elements of physical examination that were omitted, create a list of elements worth focusing on.)
[Document patient's presenting symptoms, complaints, and relevant medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Describe any physical examination findings, diagnostic test results, and other relevant clinical information] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Mention any differential diagnoses considered and the rationale for ruling them out or considering them] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Provide ICD-10 code with text name of diagnosis, based strictly on explicitly provided clinical information] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)