Scribe BC - 811 Consult

**ID:** - John Smith, 45-year-old male **CC:** - Chest pain **HPI:** - The patient presents with sudden onset of sharp, left-sided chest pain that started approximately 2 hours ago. The pain is described as a stabbing sensation, radiating to the left arm. It is exacerbated by deep breathing and movement. The patient denies any recent trauma. - **Review of systems:** - Constitutional symptoms: Denies fever, chills, night sweats, fatigue, or malaise. - Eyes: Denies eye pain, swelling, redness, foreign body sensation, discharge, or vision changes. - Ears, Nose, Mouth, Throat: Denies hearing changes, ear pain, nasal congestion, sinus pain, hoarseness, sore throat, rhinorrhea, or swallowing difficulty. - Cardiovascular: Reports chest pain, denies shortness of breath (SOB), paroxysmal nocturnal dyspnea (PND), dyspnea on exertion, orthopnea, claudication, edema, or palpitations. - Respiratory: Denies cough or sputum production, denies wheezing or smoke exposure, reports dyspnea. - Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, abdominal pain, heartburn, anorexia, dysphagia, hematochezia, melena, flatulence, or jaundice. - Genitourinary: Denies dysmenorrhea, dysfunctional uterine bleeding (DUB), dyspareunia, dysuria, urinary frequency, hematuria, urinary incontinence, urgency, flank pain, changes in urinary flow, or hesitancy. - Musculoskeletal: Denies arthralgias, myalgias, joint swelling, joint stiffness, back pain, neck pain, or injury history. - Integumentary (Skin): Denies skin lesions, pruritis, hair changes, breast/skin changes, or nipple discharge. - Neurological: Denies weakness, numbness, paresthesias, loss of consciousness, syncope, dizziness, headache, coordination changes, or recent falls. - Psychiatric: Denies anxiety/panic, depression, insomnia, personality changes, delusions, rumination, suicidal ideation/homicidal ideation/auditory hallucinations/visual hallucinations, social issues, memory changes, violence/abuse history, or eating concerns. - Endocrine: Denies polyuria, polydipsia, or temperature intolerance. - Hematologic/Lymphatic: Denies bruising, bleeding, transfusion history, or lymphadenopathy. - Allergic/Immunologic: Denies allergic reactions or auto-immune disorders. **PMHX:** - Hypertension, treated with Lisinopril. **MEDS:** - Lisinopril 10mg daily, Aspirin 81mg daily. **ALLERGIES:** - NKDA **FAMILY HISTORY:** - Father with history of coronary artery disease. **SOCIAL HX:** - Smokes one pack of cigarettes per day for 20 years. Drinks alcohol occasionally. Works as a construction worker. **IMPRESSION / PLAN:** - Impression: Possible acute coronary syndrome (ACS). Differential diagnoses include: unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). - Plan: Administer oxygen, establish IV access, obtain ECG, cardiac markers (troponin), and chest X-ray. Administer aspirin 325mg, and consider nitroglycerin and morphine for pain management. Admit to the cardiac unit for further monitoring and management. - Referrals: Cardiology consultation. - Discharge Criteria: Patient will be discharged when chest pain is resolved, cardiac markers are trending down, and ECG shows no new changes. - Follow-up: Cardiology follow-up in 2 weeks. Return to the emergency department if chest pain recurs or worsens. "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"