Emergency Room Note

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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.

Laboratory and Imaging:

• CBC: within normal limits

• CMP: within normal limits

• Troponin: pending

• ECG: ST-segment elevation in leads II, III, and aVF.

Assessment:

1. Acute coronary syndrome (ACS) – possible ST-Elevation Myocardial Infarction (STEMI)

2. Hypertension

3. Diabetes Mellitus

Plan:

• Administer aspirin 325 mg chewed

• Administer nitroglycerin sublingual for chest pain

• Initiate heparin drip

• Consult cardiology for cardiac catheterization

• Monitor vitals and repeat ECG in 30 minutes

• Educate the patient regarding his condition and treatment plan

Disposition:

The patient will be admitted to the telemetry unit for further monitoring and management.

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