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.
Chief Complaint: [describe the primary reason for the patient's visit, focusing on the main symptom or problem] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
History of Presenting Illness: [detail the patient's current medical condition, including the onset, nature, progression, and any associated symptoms, as well as relevant background information] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
Detailed history of investigations and findings performed in the emergency department or transferring facility: [provide a comprehensive account of medical tests, procedures, and their results conducted in the emergency department or a transferring facility] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
Past Medical History: [list all significant past medical conditions and diagnoses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a comma-separated list.)
Home Medications: [enumerate all medications the patient is currently taking at home, including dosages and frequencies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a comma-separated list.)
Allergies: [document any known allergies, specifying the type of allergy if mentioned] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Social History: [describe relevant social factors such as smoking status, alcohol consumption, marital status, and living arrangements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Family History: [record any significant medical conditions present in the patient's family members] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Review of Systems:
Constitutional symptoms: [document any reported constitutional symptoms such as fatigue or malaise] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Eyes: [document any reported eye symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Ears, Nose, Mouth, Throat: [document any reported ear, nose, mouth, or throat symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Cardiovascular: [document any reported cardiovascular symptoms such as chest pain or palpitations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Respiratory: [document any reported respiratory symptoms such as cough or dyspnea] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Gastrointestinal: [document any reported gastrointestinal symptoms such as nausea, vomiting, or abdominal pain] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Genitourinary: [document any reported genitourinary symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Musculoskeletal: [document any reported musculoskeletal symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Integumentary (Skin): [document any reported integumentary symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Neurological: [document any reported neurological symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Psychiatric: [document any reported psychiatric symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Endocrine: [document any reported endocrine symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Hematologic/Lymphatic: [document any reported hematologic or lymphatic symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Allergic/Immunologic: [document any reported allergic or immunologic symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Physical Exam:
Vitals: [record the patient's vital signs, including blood pressure, heart rate, and temperature] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a comma-separated list.)
Abdominal examination: [describe findings from the abdominal examination, including tenderness or guarding] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Lab Results:
[document relevant laboratory test results, including specific elevated levels or other findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Imaging Results:
[document findings from imaging studies, including specific diagnoses or observations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Assessment/Plan:
1. [state the primary medical diagnosis or problem] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
- Impression: [summarize the clinical impression for the primary diagnosis] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
- Differential diagnosis: [list potential alternative diagnoses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a comma-separated list.)
- Investigations planned: [outline any further investigations or tests that are planned] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a comma-separated list.)
- Treatment planned: [detail the planned treatment strategies, including medications, procedures, or lifestyle modifications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a comma-separated list.)
- Relevant referrals: [list any specialists or services to which the patient will be referred] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Two Midnight Documentation
[document the expected duration of the patient's hospital stay relative to the two-midnight rule, including reasons if applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
Total time spent: [record the total time spent on the patient encounter] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
