ED Note
Presenting Complaint:
Patient presents with sudden onset of severe chest pain, radiating to the left arm, and shortness of breath. Symptoms began approximately 30 minutes prior to arrival.
History of Present Illness:
The patient, a 62-year-old male, reports a sudden, crushing chest pain that started while he was at home. He describes the pain as a pressure sensation, rated 9/10 in severity. The pain radiates down his left arm and is associated with shortness of breath, diaphoresis, and nausea. He denies any recent trauma or injury. He has tried taking an aspirin, but the pain has not improved.
Systems Review:
Patient reports shortness of breath, chest pain, and nausea. Denies fever, chills, cough, abdominal pain, headache, or vision changes.
PMHx:
Hypertension, Hyperlipidemia, and a history of a previous myocardial infarction 5 years ago.
Meds:
Metoprolol 50mg daily, Atorvastatin 20mg daily, Aspirin 81mg daily, and Lisinopril 10mg daily.
Allergies:
NKDA (No Known Drug Allergies)
Social:
Patient is a former smoker, having quit 10 years ago. Drinks alcohol occasionally, denies illicit drug use. Lives at home with his wife.
FHx:
Father had a history of coronary artery disease and died at age 70 from a heart attack. Mother has hypertension.
O/e:
Vitals: BP 160/90, HR 110 bpm, RR 24, SpO2 92% on room air, Temp 37.1°C.
General: Appears in acute distress, diaphoretic.
Cardiovascular: Regular rhythm, S1S2, no murmurs, rubs, or gallops.
Respiratory: Bilateral decreased breath sounds, with some wheezing.
Neurological: Alert and oriented to person, place, and time.
Ix:
ECG: ST-segment elevation in leads II, III, and aVF.
Cardiac Enzymes: Troponin I elevated.
Chest X-ray: Mild pulmonary congestion.
Impression:
Acute Myocardial Infarction (STEMI).
Plan/Disposition:
* Administer oxygen via nasal cannula.
* Administer aspirin 325mg, chewable.
* Administer nitroglycerin sublingually.
* Administer morphine for pain control.
* Activate the cardiac catheterisation lab.
* Admit to the Cardiac Intensive Care Unit (CICU).
* Consult Cardiology.
* Follow up with cardiology in the morning.
* Patient admitted to the CICU for further management and monitoring.
ED Note
Presenting Complaint:
[document the patient's primary reason for visiting the emergency department, including symptoms and duration] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
History of Present Illness:
[describe the detailed history of the patient's current illness, including onset, location, duration, characteristics, aggravating and relieving factors, and associated symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Systems Review:
[conduct a review of systems, documenting any positive or negative findings across various body systems] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
PMHx:
[document the patient's past medical history, including chronic illnesses, hospitalisations, and surgeries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Meds:
[list all current medications the patient is taking, including dosages and over-the-counter supplements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Allergies:
[document any known allergies, including drug, food, and environmental allergies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Social:
[describe relevant social history, including smoking, alcohol use, drug use, and living situation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
FHx:
[document any relevant family medical history, including chronic illnesses and genetic conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
O/e:
[document the findings from the physical examination, including vital signs and examination of relevant body systems] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Ix:
[list any diagnostic studies performed, including lab tests, imaging, and their results] (Only include if explicitly mentioned in transcript, context or clinical note, else just leave section header.)
Impression:
[provide a list of the clinical issues, including differential diagnoses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Plan/Disposition:
[outline the management plan, including treatments, medications, follow-up instructions, and any referrals] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List as bullet points.)
[document the patient's disposition, including whether they were admitted, discharged, or transferred, and any follow-up plans] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List as bullet points.)
(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.)