General Practitioner-Vorlage
ED note *
Eine professionelle General Practitioner-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need to document a patient's visit to the Emergency Department? This ED note template is designed for quick and efficient documentation, perfect for busy clinicians. It helps you capture essential information like the patient's presenting complaint, medical history, examination findings, investigations, and the plan of care. With Heidi, this template can be easily populated from a patient's visit transcript, saving you time and ensuring comprehensive medical records. This template is ideal for General Practitioners working in the ED, and can be used to create a detailed record of a patient's presentation and management. The date of this example note is 1 November 2024.
Vorlagenvorschau
**PC:**
- Chest pain, 67 year old male
**HISTORY OF PC:**
- Sudden onset 2 hours prior to presentation
- Sharp, crushing chest pain radiating to left arm
- Associated with shortness of breath and diaphoresis
- Possible trigger: exertion during gardening
- No relevant background information
**Back Pain RED FLAGS:**
No weakness
No bladder dysfunction, has full control, no LUTs
No bowel problems
No unexplained weight loss
No trauma/injury
No central back pain
No fevers
No IVDU
No immunosuppression
No hx of malignancy
No saddle paraesthesia
**SYSTEMS REVIEW:**
- Nil dizziness, headache, visual disturbance.
Nil runny nose, colds, fevers.
Nil cough, shortness of breath.
Nil chest pain, palpitations, orthopnoea.
Nil nausea, vomiting, diarrhoea, constipation, abdominal pain.
Nil dysuria, frequency, change in urine volume / colour / smell.
Nil swelling, redness, pain in legs.
**MANAGEMENT EN ROUTE WITH NSWAS:**
- Oxygen administered, ECG performed, aspirin given.
- Patient's chest pain partially relieved.
**MEDICAL HX:**
- Hypertension
- Hypercholesterolemia
- Previous myocardial infarction
- No relevant surgical history
- No relevant mental health history
- Cardiology
**MEDICATIONS:**
- Aspirin 100mg daily
- Atorvastatin 40mg daily
- Lisinopril 20mg daily
**ALLERGIES:**
- Penicillin
**SOCIAL HX:**
- Smoker, 20 cigarettes per day for 40 years
- Drinks alcohol socially
- No social drug use history
**FAMILY HISTORY:**
- Father died of a heart attack at age 65
**IMMUNISATION HISTORY:**
- Up to date with influenza and pneumococcal vaccines
**EXAMINATION:**
Vitals:
- Temperature: 37.1°C
- Blood pressure: 160/90 mmHg
- Heart rate: 100 beats/minute
- Oxygen saturation: 94%
General appearance and status: Appears unwell, diaphoretic, in distress.
Cardiovascular examination findings: S1 and S2 present, no murmurs, rubs, or gallops.
Respiratory examination findings: Mild shortness of breath, clear lung sounds bilaterally.
**INVESTIGATIONS:**
Bloods:
- Troponin elevated
CG4 / VBG
- pH 7.35
- CO2 35
- BE -2
- HCO3 20
- Lac 2.1
Chem8
- Na 140
- K 4.0
- Gluc 120
- Creat 1.0
- Hb 14.5
iSTAT Troponin - 0.15
Radiology:
- ECG showed ST-segment elevation in inferior leads.
**IMPRESSION:**
- Acute myocardial infarction
- Hypertension
**PROGRESS MANAGEMENT IN EMERGENCY:**
- Administered oxygen, IV access established, and morphine given for pain.
- Chest pain improved slightly.
- Repeat troponin pending.
**PLAN:**
- Admit to the Coronary Care Unit.
- Cardiology consult.
- Aspirin, clopidogrel, and enoxaparin to be administered.
- Continuous cardiac monitoring.
- Diet as tolerated.
- IV fluids as needed.
- Follow-up with cardiology in the morning.
- Contact cardiologist if chest pain worsens or new symptoms develop.
Dr. Jane Smith
GP Registrar
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