ER Note

45-year-old male presenting with severe chest pain PMH Hypertension, Hyperlipidemia Appendectomy in 2005 Father had a heart attack at age 60 Habits (include in PMH section) Smokes 10 cigarettes per day No illicit drug use Occasional alcohol consumption Meds cf list Aspirin 81 mg daily, Lisinopril 10 mg daily No natural products used HPI Severe, crushing chest pain radiating to the left arm, 8/10 on pain scale, worsens with exertion, improves with rest, started 2 hours ago Associated symptoms: shortness of breath, nausea Cardio Chest pain, shortness of breath, no orthopnea, no paroxysmal nocturnal dyspnea, no leg swelling, no palpitations, no syncope Respiratory Shortness of breath, no cough, no expectoration, no hemoptysis No phx of DVT or PE, no calf symptoms, no recent immobilisation, no hemoptysis, no OCP or hormone use Abdominal Nausea, no vomiting, no diarrhea, no hematemesis, no melena, no bright red blood per rectum, no constipation, no abdominal pain, no rectal pain, no alcohol consumption, no consumption of anti-inflammatories, no urinary symptoms (no hematuria, no dysuria, no frequency) Gyne/Gu No urinary symptoms (no dysuria, no frequency, no hematuria) Neurological symptoms No headache, no head trauma, no aphasia, no ataxia, no dysarthria, no dysphagia, no dysphonia, no weakness in a limb, no paresthesias or loss of sensation in a limb, no vision change (diplopia or loss vision), no peripheral neuro sx (sensory or motor) Constitutional symptoms No fever, no chills, no myalgia, no arthralgia, no unexplained fevers, no unexplained weight loss, no swollen lymph node, no sick contact Eyes No eye pain, no swelling, no redness, no foreign body sensation, no discharge, no vision changes Ears, Nose, Mouth, Throat No hearing changes, no ear pain, no nasal congestion, no sinus pain, no hoarseness, no sore throat, no rhinorrhea, no swallowing difficulty PE Alert and oriented, appears in mild distress VSS H/N N Heart Ns1s2, no murmurs Lungs: clear GEAB Abdo: soft, no guarding, no rebound, no peritoneal I/P Acute coronary syndrome, likely unstable angina, based on chest pain characteristics and risk factors Consider myocardial infarction, rule out with ECG and cardiac enzymes Orders: ECG, cardiac enzymes, chest X-ray, continue aspirin, start nitroglycerin Reassessment 1 November 2024, 14:00 Patient's chest pain has decreased to 4/10 after nitroglycerin administration Exam No changes in physical exam I/P Continue monitoring, consider cardiology consult if symptoms persist