Scribe BC - ED General Note

**ID:** - John Smith, 35 year old male **CC:** - Chest pain **HPI:** - The patient presents with sudden onset of sharp, left-sided chest pain that began approximately 2 hours prior to arrival. The pain is described as a stabbing sensation, radiating to the left shoulder. It is exacerbated by deep breaths and movement. The patient denies any recent trauma or injury. There is no history of similar episodes. The patient reports associated shortness of breath and mild diaphoresis. No fever, cough, or other associated symptoms are reported. **PMHX:** - Hypertension, controlled with medication. **MEDS:** - Lisinopril 20mg daily. **ALLERGIES:** - NKDA **FAMILY HISTORY:** - Father with history of coronary artery disease. **SOCIAL HX:** - Smoker (1 pack per day for 15 years). Drinks alcohol occasionally. **PHYSICAL EXAM:** - Vital signs: BP 160/90, HR 110, RR 24, SpO2 94% on room air, Temp 37.1C - HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light. No nasal discharge or congestion. Oropharynx clear. - CVS: normal S1 / S2, no S3/S4 or murmurs - Resp: chest clear to auscultation, no crackles / wheezes, no crepitus - Abdomen: soft, non-tender, no peritonitis or guarding, no masses - Extremities: No edema, good peripheral pulses. - Back exam (ASIA scale): General: Tenderness to palpation to: None Bruising: None Scars: None **INVESTIGATIONS:** - ECG performed, showing ST-segment elevation in leads II, III, and aVF. Cardiac enzymes drawn. **REASSESSMENT:** Reassessment at 10:00 due to change in condition / treatment plan. Re-examined: Chest. The patient's chest pain has improved slightly after administration of aspirin and nitroglycerin. Plan changed: The patient was given oxygen and placed on a cardiac monitor. The patient was given aspirin and nitroglycerin. The patient was given morphine for pain control. **PROCEDURE NOTE:** - IV access established. 12-lead ECG performed. Aspirin 325mg administered. Nitroglycerin 0.4mg sublingual administered. **IMPRESSION / PLAN:** - Impression: Acute myocardial infarction. Differential diagnoses include unstable angina, pulmonary embolism, and aortic dissection. - Plan: Administer oxygen. Continuous cardiac monitoring. IV access. Aspirin 325mg PO. Nitroglycerin 0.4mg SL. Morphine 2mg IV for pain. Transfer to cardiac catheterization lab. - Referrals: Cardiology consultation. - Discharge Criteria: N/A - Reasons to return to the emergency department: Worsening chest pain, shortness of breath, or any new symptoms. “The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks.”