Chest pain ER Admission Medical Report Format #1
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who states she has been feeling like something is in her chest every time she eats. For the last 2-1/2 to 3 weeks, she has had a sharp pain in the right chest with swallowing either liquids or solids. They do not feel like they get stuck. They pass fine and it only lasts a couple of seconds. She has been coughing a lot, as well with whitish sputum. She has a foul taste in mouth when she wakes up in the morning and a little bit of a sore throat.
She does use caffeine, nicotine and occasional alcohol. She takes ibuprofen on a regular basis secondary to a herniated disk. The patient denies any esophageal problems, either herself or in the family. She has never had surgery to the chest. She states it hurts as well to cough a little bit. She states the pain is sharp and is 2 to 6/10. Nursing notes were reviewed.
REVIEW OF SYSTEMS: Negative for any fever, chills, melena, hematochezia, vomiting, nausea, shortness of breath, weight loss, weight gain, leg swelling and abdominal pain. The remainder of her review of systems is reviewed and negative.
PAST MEDICAL/SURGICAL HISTORY: Recent UTI.
ALLERGIES: None.
MEDICATIONS: Recent antibiotic.
SOCIAL HISTORY: Positive smoker.
FAMILY HISTORY: Noncontributory.
IMMUNIZATION STATUS: Noncontributory.
PHYSICAL EXAMINATION:
GENERAL: Well-developed, nontoxic, polite and cooperative.
VITAL SIGNS: Temperature 98.4, pulse 98, respiratory rate 18, blood pressure 134/82, room air pulse ox is 96% and is within normal limits.
HEENT: Anicteric sclerae. Pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear. Moist mucous membranes. No stridor. Bilateral TMs are clear.
CHEST WALL: Nontender.
HEART: Regular rate and rhythm. No murmurs, heaves, gallops or rubs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft. Positive bowel sounds. Nontender. No organomegaly.
EXTREMITIES: No clubbing, cyanosis or edema. No Homans or palpable cords.
SKIN: No rash.
DIAGNOSTIC STUDIES: A chest x-ray, 2-view, PA and lateral, interpreted by the radiologist and reviewed by us as normal.
ADDITIONAL DATA: None.
EMERGENCY DEPARTMENT COURSE: She remained stable here.
PROCEDURE: None.
CRITICAL CARE: None.
CONSULTATIONS: None.
MEDICAL DECISION MAKING: We do not feel we are dealing with entities that include but are not limited to an ACS, pericarditis, myocarditis, Boerhaave syndrome, Mallory-Weiss tear, esophageal obstruction, mass in the chest, pneumonia or pneumothorax either. We think this individual is probably dealing with a chest pain that is probably more related to reflux as she gets it with swallowing. She may have irritation in the distal esophagus. She admits to a foul taste in her mouth with awakening as well as a soreness of the throat. Perhaps, she is having reflux and the stomach acid is coming up into those parts of the nasopharyngeal region. Avoidance of caffeine, nicotine and alcohol is crucial. We have told her she should probably stay on the ibuprofen for the chronic back problems, and we will place her on an H2 blocker as cost is an issue.
IMPRESSION:
1. Atypical chest pain.
2. GERD.
PLAN:
1. Stop smoking, caffeine and alcohol.
2. Return if cannot swallow fluids, profuse vomiting, fever or worse in any way.
3. Follow up with Dr. John Doe in 2 days.
4. A prescription for Pepcid is given.
Chest pain ER Admission Medical Report Format #2
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who reports chest pain, just left to his sternum, that has been there for a week now. He states it is sort of hurting quite a bit if he coughs or sneezes and somewhat when he moves around. He has had no fevers, chills or upper respiratory congestion. He has an occasional smoker’s cough but no productive cough. There is no nausea, no vomiting, no diarrhea, no dysuria, urgency or frequency.
PAST MEDICAL HISTORY: Otherwise unremarkable.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: He is a smoker.
REVIEW OF SYSTEMS: All other systems are reviewed and negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 132/82, temperature 98.2, pulse 92, respirations 16, and 99% on room air.
GENERAL: A (XX)-year-old, awake, alert, comfortable appearing, no acute distress.
HEENT: Head is normocephalic, atraumatic. Pupils are equal, round, reactive to light. Extraocular muscles are intact. No nasal discharge. No facial trauma. Intraoral exam shows moist mucous membranes with no tonsillar enlargement or exudate. Tympanic membranes are normal. The canals are clear.
NECK: Supple with no cervical lymphadenopathy No meningismus. No goiter.
CARDIOVASCULAR: Regular rate, without murmur, rub or gallop.
PULMONARY: Equal breath sounds bilaterally with no wheezing, rales or rhonchi. There is no chest wall tenderness or instability.
ABDOMEN: He does have reproducible tenderness to palpation just left of his sternum around the fourth intercostal space. There are no bruising, erythema or skin changes noted.
EXTREMITIES: Strong peripheral pulses. There is no clubbing, no cyanosis and no edema.
SKIN: No rash.
EMERGENCY DEPARTMENT COURSE: On his evaluation here in the emergency room, EKG sinus rhythm rate of 76, no ischemic changes. His chest x-ray shows normal cardiac silhouette, clear lung fields, no pneumothorax, no bony abnormalities. He was given IM Toradol.
DISPOSITION: Discharged home in good condition.
DIAGNOSIS: Chest wall pain, possibly some mild costochondritis.
PLAN:
1. He is prescribed Anaprox.
2. He is to rest.
3. Follow up with his primary care provider.
4. Return as needed.
Chest pain ER Admission Medical Report Format #3
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman with a history of coronary artery disease, status post quadruple bypass and multiple MIs and stenting as recently as 1 week ago to the LAD, who comes to the emergency department saying he was watching TV at 12:45 a.m. when he had the abrupt onset of substernal chest pain with radiation to his jaw similar to his prior anginal equivalent. This was associated with nausea and diaphoresis, no vomiting. He immediately called the ambulance, and his wife gave him two sublingual nitroglycerins, which took his pain from an 8/10 down to approximately 6/10.
En route, he received 325 mg of aspirin as well as an additional nitro spray, which reduced his pain to a 4. He was brought to the emergency department still complaining of substernal pain. He states that he has had no other fevers, chills, nausea or vomiting. He has had no dyspnea on exertion or exertional pain and this pain has not happened since his last stent.
REVIEW OF SYSTEMS: As per HPI. All other systems are reviewed and are negative.
PAST MEDICAL HISTORY:
1. History of stroke in the room.
2. Past diabetes.
3. Coronary artery disease, status post CABG and multiple MIs and status post PTCA as recently as MM/DD/YYYY.
MEDICATIONS: See nursing notes.
ALLERGIES: Penicillin.
SOCIAL HISTORY: Denies any tobacco use, alcohol consumption or IV or recreational drug use.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2, pulse 100, blood pressure 118/68, respirations 18, oxygen saturation 99% on nonrebreather.
GENERAL: He is a well-appearing male in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. Oropharynx is moist without erythema or exudate.
NECK: Supple without lymphadenopathy or thyromegaly.
LUNGS: Clear to auscultation bilaterally with good air movement.
CARDIOVASCULAR: Regular rate and rhythm with no audible murmurs, rubs or gallops. He had 2+ carotid, radial and dorsalis pedis pulses.
ABDOMEN: Soft, nontender, and nondistended without rebound or guarding.
EXTREMITIES: Warm without clubbing, cyanosis or edema.
SKIN: Warm without evidence of rash or petechia.
NEUROLOGIC: He is alert and oriented x3 with cranial nerves II-XII intact. No focal motor deficits.
PSYCHIATRIC: Mood and affect were appropriate to the examination.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. An EKG was immediately performed, which showed no change from prior. IV was placed. Labs were drawn. Chest x-ray was performed. The patient was given an inch of nitro paste and continued to have pain. Nitroglycerin drip was ordered, however, with 5 mg morphine. His pain was completely controlled, and, therefore, the nitrate was discontinued. It was never initiated. He was heparinized for ACS protocol and was discussed with the CCU team for admission.
LABORATORY DATA: Serum chemistries were within normal limits with a creatinine 1.2 and a mildly elevated glucose of 244. CBC was within normal limits with a mild left shift and his white count was 7.8. His CK-MB and troponin I was negative on the first set. BNP was normal at 63. Coagulation studies were within normal limits. Chest x-ray shows no acute cardiopulmonary pathology and EKG performed for indication of chest pain showed normal sinus rhythm at a rate of 74 beats per minute. He had Q waves in lead III, which are not new. He had no acute ST elevations or T-wave inversions. He had normal intervals with QTc 404 milliseconds in comparison to prior EKG dated MM/DD/YYYY. There was no significant change.
MEDICAL DECISION MAKING: See above. This patient presents approximately 1 week after catheterization to the LAD with abrupt onset of unstable angina similar to his prior anginal equivalent. He has no indication for urgent catheterization at this time as his EKG is unremarkable; however, given his history, we feel he is at extremely high risk of acute coronary syndrome versus unstable angina, and therefore, he will be heparinized and admitted to the CCU service.
IMPRESSION: Chest pain, rule out acute coronary syndrome.
DISPOSITION: The patient being admitted in stable condition.
PLAN: Further work and evaluation by the CCU team.
