Free Emergency Room Note Template

Emergency Room Note

Patient Name: Jarvis White
MRN: 123456
Date: October 8, 2050
Time: 14:30
Attending Physician: Dr. [Your Name]

Chief Complaint:

Chest pain for 30 minutes.

History of Present Illness:

Mr. White is a 55-year-old male who presents to the emergency department with complaints of acute chest pain that started approximately 30 minutes before arrival. The pain is described as a pressure sensation in the center of the chest, radiating to the left arm. He reports associated symptoms of shortness of breath and diaphoresis. The patient denies any nausea, vomiting, or recent trauma.

Past Medical History:

Hypertension
Hyperlipidemia
Diabetes Mellitus Type II

Medications:

Lisinopril 20 mg daily
Atorvastatin 40 mg daily
Metformin 500 mg twice daily

Allergies:

No known drug allergies.

Social History:

Smoker (1 pack/day for 20 years)
Occasional alcohol use

Family History:

Father: myocardial infarction at age 60
Mother: alive, no significant history

Review of Systems:

Cardiovascular: Chest pain, palpitations
Respiratory: Shortness of breath
Gastrointestinal: No nausea or vomiting
Neurological: No dizziness or headache

Physical Examination:

Vital Signs:
- BP: 150/90 mmHg
- HR: 98 bpm
- RR: 20 breaths/min
- Temp: 98.6°F
- O2 Sat: 95% on room air
General: Alert, in mild distress due to pain.
Cardiovascular: Regular rate and rhythm, no murmurs.
Respiratory: Clear to auscultation bilaterally.
Gastrointestinal: Soft, non-tender, no distension.
Neurological: Alert and oriented, no focal deficits.