[Date, month, year] 1 November 2024
[Time] 14:35
**Presenting complaint**
Chest pain
**History of presenting complaint**
- Patient reports sudden onset of sharp chest pain radiating to the left arm.
- Pain began approximately 30 minutes prior to arrival.
- Associated with shortness of breath and diaphoresis.
- No recent trauma.
- No alleviating factors.
- Pain is worsened by deep inspiration.
**Past medical history**
- Hypertension
- Hyperlipidemia
**Medication and allergies**
- Aspirin 75mg daily
- Atorvastatin 20mg nocte
- _NKDA_
**Social history**
- Smoker, 20 cigarettes per day.
- Works as a construction worker.
- Independent with ADLs.
- No known social issues.
**Examination**
- Airway: Patent.
- Breathing: Increased respiratory rate, bilateral equal air entry, SpO2 94% on room air.
- Circulation: Tachycardic, BP 160/90 mmHg, peripheral pulses palpable.
- Disability/Neurological: Alert and oriented, GCS 15.
- Exposure/Other injury or physical findings: Diaphoretic, no obvious injury.
**Investigations**
- ECG performed at 14:40, showing ST-segment elevation in leads II, III, and aVF.
- Cardiac enzymes pending.
**Impression**
Acute myocardial infarction.
**Clinical management**
- Administered 300mg Aspirin PO.
- Administered 5mg Morphine IV.
**Consent**
"Verbal consent obtained from patient"
[Dr. Emily Carter, Emergency Medicine Specialist, GMC 1234567]
[Date, month, year]
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[Time]
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**Presenting complaint**
[Presenting complaint]
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**History of presenting complaint**
[Provide detailed chronological history with each sentence starting on a new line using dash symbol. Include relevant system findings in this section if present. Delete section if not mentioned.]
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**Past medical history**
- [Past medical history item 1]
- [Past medical history item 2]
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**Medication and allergies**
- [Medication 1]
- [Medication 2]
- _[Allergy noted]_
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**Social history**
- [Smoking status, alcohol or drug use]
- [Occupation if mentioned]
- [ADLs and any assistance or carers involved]
- [Any other relevant social issues]
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**Examination**
- [Airway findings]
- [Breathing findings]
- [Circulation findings]
- [Disability/Neurological findings]
- [Exposure/Other injury or physical findings]
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**Investigations**
- [Investigation with date if stated]
- [Next investigation]
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**Impression**
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**Clinical management**
- [Management step 1]
- [Management step 2]
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**Consent**
"Verbal consent obtained from patient"
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[Clinician’s full name, professional title, and registration number]
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(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 dash symbols as needed to capture all the relevant information from the transcript.)