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Simple Hospital Medical Report

Simple Hospital Medical Report

Patient Information

  • Name: [Patient's Name]

  • Date of Birth: [Patient's Birthdate]

  • Gender: Male

  • Address: [Patient's Address]

  • Phone Number: [Patient's Contact Number]

  • Email: [Patient's Email]

Chief Complaint

The patient presented to the emergency department with severe, acute chest pain radiating to the left arm and associated with shortness of breath.

History of Present Illness

[Patient's Name], a 44-year-old male with a medical history significant for hypertension and hyperlipidemia, reported experiencing a sudden onset of chest pain approximately two hours before arriving at the hospital. The pain is described as sharp and persistent, escalating in intensity with physical exertion. The patient also noted episodes of diaphoresis (sweating) and mild nausea but denies any vomiting. He has no prior history of similar symptoms or cardiac events.

Past Medical History

  • Hypertension: Diagnosed in 2056, managed with Lisinopril 10 mg daily.

  • Hyperlipidemia: Diagnosed in 2053, treated with Atorvastatin 20 mg daily.

  • Surgeries: None reported.

  • Allergies: Penicillin (causes rash).

  • Current Medications: Lisinopril, Atorvastatin.

Physical Examination

  • Vital Signs:

    • Temperature: 98.6°F

    • Blood Pressure: 150/95 mmHg

    • Pulse: 110 BPM (tachycardic)

    • Respiratory Rate: 22 RPM

  • General Appearance: The patient appears alert but in moderate distress due to chest pain.

  • HEENT: Normocephalic, atraumatic; oropharynx clear without edema or erythema.

  • Cardiovascular: Regular rhythm with a rate of 110 BPM; no audible murmurs, gallops, or rubs detected.

  • Respiratory: Slight wheezing on expiration; lung fields clear to auscultation bilaterally, no crackles or rhonchi.

  • Abdomen: Soft, non-tender, no distension or organomegaly detected.

  • Extremities: No edema; distal pulses intact and symmetrical.

  • Neurological: Patient is alert and oriented to time, place, and person; no neurological deficits noted.

Diagnostic Tests/Procedures

  • Electrocardiogram (ECG): Demonstrated ST-segment elevation in leads II, III, and aVF, suggestive of inferior wall STEMI.

  • Cardiac Enzymes: Troponin I levels were elevated at 1.5 ng/mL, indicating myocardial injury.

  • Chest X-ray: No acute cardiopulmonary abnormalities; heart size within normal limits.

  • Complete Blood Count (CBC): Mild leukocytosis observed with WBC count at 11,000/uL.

Assessment

The clinical presentation and diagnostic findings are consistent with an acute myocardial infarction (STEMI), likely resulting from occlusion of the right coronary artery.

Plan

  1. Immediate Treatment Protocol:

    • Administer 325 mg of chewable aspirin to inhibit platelet aggregation.

    • Initiate intravenous nitroglycerin infusion to manage chest pain and improve myocardial oxygenation.

    • Prepare the patient for cardiac catheterization to assess coronary artery status and possible intervention.

  2. Consultations:

    • Request cardiology consult for evaluation and management of acute coronary syndrome.

  3. Monitoring:

    • Continuous telemetry monitoring for cardiac rhythm changes.

    • Vital signs to be monitored every hour to assess stability and response to treatment.

  4. Follow-up:

    • Review lab results, imaging studies, and clinical status to guide further management decisions.

[Your Name]
Internal Medicine

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