Emergency Medicine Expert's Documentation Template

Chief Complaint: Intense chest pain and difficulty breathing
History of Presenting Illness: The patient, a 58-year-old male, arrived at the emergency department with a sudden onset of intense chest pain extending to the left arm, along with difficulty breathing. These symptoms started about 2 hours ago while the patient was at rest. The pain is described as crushing and is rated 9/10 in intensity. The patient reports no relieving factors and took aspirin 30 minutes before arrival. He was last known to be at his usual baseline yesterday. The patient was brought in by EMS, who provided oxygen during transport. He has a history of high blood pressure and high cholesterol, with no recent hospitalizations or changes in medication.
Past Medical History: High blood pressure, High cholesterol
Medication History: Lisinopril 10 mg daily, Atorvastatin 20 mg daily, Aspirin 81 mg daily. No known drug allergies.
Social History: Smokes 1 pack of cigarettes per day, denies alcohol or illicit drug use.
Family History: Father experienced a heart attack at age 60.
Review of Systems:
- Constitutional symptoms: Denies weight change, fever, chills, night sweats, fatigue, malaise.
- Eyes: Denies eye pain, swelling, redness, foreign body sensation, discharge, vision changes.
- Ears, Nose, Mouth, Throat: Denies hearing changes, ear pain, nasal congestion, sinus pain, hoarseness, sore throat, rhinorrhea, swallowing difficulty.
- Cardiovascular: Reports chest pain and difficulty breathing.
- Respiratory: Denies cough, sputum production, wheezing, smoke exposure, dyspnea.
- Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, abdominal pain, heartburn, anorexia, dysphagia, hematochezia, melena, flatulence, jaundice.
- Genitourinary: Denies dysmenorrhea, dysfunctional uterine bleeding, dyspareunia, dysuria, urinary frequency, hematuria, urinary incontinence, urgency, flank pain, changes in urinary flow, hesitancy.
- Musculoskeletal: Denies arthralgias, myalgias, joint swelling, joint stiffness, back pain, neck pain, injury history.
- Integumentary (Skin): Denies skin lesions, pruritis, hair changes, breast/skin changes, nipple discharge.
- Neurological: Denies weakness, numbness, paresthesias, loss of consciousness, syncope, dizziness, headache, coordination changes, recent falls.
- Psychiatric: Denies anxiety/panic, depression, insomnia, personality changes, delusions, rumination, suicidal ideation/homicidal ideation/auditory hallucinations/visual hallucinations, social issues, memory changes, violence/abuse history, eating concerns.
- Endocrine: Denies polyuria, polydipsia, temperature intolerance.
- Hematologic/Lymphatic: Denies bruising, bleeding, transfusion history, lymphadenopathy.
- Allergic/Immunologic: Denies allergic reactions, auto-immune disorders.
Objective:
- Vitals: Blood Pressure 160/90 mmHg, Heart Rate 110 bpm, Temperature 37.0°C, Oxygen Saturation 95% on room air.
- General: Alert and oriented, in moderate distress due to pain.
- Cardiovascular: Tachycardic, regular rhythm, no murmurs, rubs, or gallops.
- Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
Investigations:
- Bloods: CBC normal, Troponins elevated.
- Imaging: Chest X-Ray normal, ECG shows ST elevation in leads II, III, and aVF.
Assessment:
- Primary Diagnosis: Acute Myocardial Infarction (ICD-10: I21.9)
- Differential Diagnosis: Ruled out pulmonary embolism and aortic dissection based on clinical presentation and imaging.
Plan:
- Immediate Management: Administered aspirin 325 mg, clopidogrel 600 mg, and started on heparin infusion.
- Investigations Planned: Cardiac catheterization planned.
- Referrals: Cardiology consultation requested.
- Discharge Criteria: Admission to the cardiac care unit for further management.
- Follow-up: Dr. Austin-John Fordham, MD will oversee the patient's care and provide further instructions post-procedure.