Scribe BC - Emerg Note Simple

Scribe BC - Emerg Note Simple **HISTORY OF PRESENTING ILLNESS** Patient presented to the emergency department with sudden onset of severe chest pain radiating to the left arm, accompanied by shortness of breath. The pain began approximately 30 minutes prior to arrival, described as a crushing sensation. The patient reports no recent trauma or injury. **RELEVANT PAST MEDICAL HISTORY** * Hypertension * Hyperlipidemia * Previous Myocardial Infarction (2018) **PHYSICAL EXAMINATION** Vitals: See nursing assessment General: Patient appears acutely unwell, diaphoretic, and in obvious distress. System-specific exam: * CVS: Heart sounds auscultated with an S3 gallop. * Resp: Bilateral crackles in the lung bases. **PROCEDURES** ECG performed, showing ST-segment elevation in leads II, III, and aVF. **INVESTIGATIONS** * ECG: ST-segment elevation in leads II, III, and aVF. * Cardiac enzymes: Elevated Troponin I. **COURSE IN ED** * Administered 300mg Aspirin PO. * Administered 0.4mg sublingual nitroglycerin. * IV access established. * Oxygen administered via nasal cannula at 4L/min. * Consulted Cardiology. **IMPRESSION AND PLAN** * Primary diagnosis: Acute Myocardial Infarction (Inferior STEMI). * Differential diagnoses: Unstable Angina, Aortic Dissection. * Immediate management plans: Transfer to the cardiac catheterisation lab for emergent PCI. * Referrals: Cardiology. * Discharge Criteria: Patient will be admitted to the ICU post-PCI. * Follow-up: Cardiology will follow up with the patient in the hospital. "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."