Clinical note · #48
Hospital & observation
Date: 2024-07-04
Admitting Physician: Dr. John Doe, MD
Chief Complaint: Chest pain
HPI
The patient is a 65-year-old male presenting with a 2-hour history of substernal chest pain radiating to the left arm. The pain is described as severe and crushing, associated with diaphoresis and nausea. The patient denies any previous history of similar symptoms.
ROS: Cardiovascular: Positive for chest pain. Respiratory: No dyspnea, no cough. Gastrointestinal: Nausea present, no vomiting.
Neurological: No headaches, no dizziness.
PFSH: Past Medical History: Hypertension, hyperlipidemia. Family History: Father had a myocardial infarction at age 70. Social History: Smoker, 1 pack per day for 40 years, occasional alcohol use.
Physical Examination
Vital Signs: BP 150/90, HR 90, RR 18, Temp 98.6°F. Cardiovascular: S1, S2 normal, no murmurs, rubs, or gallops. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, no hepatosplenomegaly. Neurological: Alert and oriented, cranial nerves intact.
MDM
EKG shows ST elevation in the anterior leads.
Troponin levels elevated.
Diagnosis: Acute myocardial infarction.
Plan
Admit to the coronary care unit (CCU).
Start aspirin, clopidogrel, and heparin.
Consult cardiology for urgent catheterization.