| **Patient: Sarah Johnson, DOB: 03/15/1978, MRN: 12345678** | |
| **CHIEF COMPLAINT:** Chest pain and shortness of breath | |
| **HISTORY OF PRESENT ILLNESS:** | |
| Sarah Johnson is a 45-year-old female who presents to the emergency department with acute onset chest pain that began approximately 2 hours ago. The patient describes the pain as sharp, substernal, radiating to her left arm and jaw. She rates the pain as 8/10 in intensity. The patient also reports associated shortness of breath, diaphoresis, and nausea. No recent trauma or exertion prior to symptom onset. | |
| **PAST MEDICAL HISTORY:** | |
| - Hypertension diagnosed 2019 | |
| - Type 2 Diabetes Mellitus since 2020 | |
| - Hyperlipidemia | |
| - Family history of coronary artery disease (father deceased at age 58 from myocardial infarction) | |
| **MEDICATIONS:** | |
| - Lisinopril 10mg daily | |
| - Metformin 1000mg twice daily | |
| - Atorvastatin 40mg daily | |
| - Aspirin 81mg daily | |
| **ALLERGIES:** Penicillin (causes rash) | |
| **SOCIAL HISTORY:** | |
| Former smoker (quit 5 years ago, 20 pack-year history). Drinks alcohol socially. Works as an accountant. | |
| **VITAL SIGNS:** | |
| - Temperature: 98.6°F (37°C) | |
| - Blood Pressure: 165/95 mmHg | |
| - Heart Rate: 102 bpm | |
| - Respiratory Rate: 22/min | |
| - Oxygen Saturation: 96% on room air | |
| **PHYSICAL EXAMINATION:** | |
| GENERAL: Alert, oriented, appears anxious and in moderate distress | |
| CARDIOVASCULAR: Tachycardic, regular rhythm, no murmurs, rubs, or gallops | |
| PULMONARY: Bilateral breath sounds clear, no wheezes or rales | |
| ABDOMEN: Soft, non-tender, no organomegaly | |
| **DIAGNOSTIC TESTS:** | |
| - ECG: ST-elevation in leads II, III, aVF consistent with inferior STEMI | |
| - Troponin I: 15.2 ng/mL (elevated, normal <0.04) | |
| - CK-MB: 45 U/L (elevated) | |
| - CBC: WBC 12,500, Hgb 13.2, Plt 285,000 | |
| - BMP: Glucose 180 mg/dL, Creatinine 1.1 mg/dL | |
| **ASSESSMENT AND PLAN:** | |
| 45-year-old female with acute ST-elevation myocardial infarction (STEMI) involving the inferior wall. | |
| 1. **Acute STEMI** - Patient meets criteria for urgent cardiac catheterization | |
| - Emergent cardiac catheterization and PCI | |
| - Dual antiplatelet therapy: Aspirin 325mg + Clopidogrel 600mg loading dose | |
| - Heparin per protocol | |
| - Metoprolol 25mg BID when hemodynamically stable | |
| 2. **Diabetes management** - Continue home Metformin, monitor glucose closely | |
| 3. **Hypertension** - Hold Lisinopril temporarily, restart when stable | |
| **DISPOSITION:** Patient transferred to cardiac catheterization lab for emergent intervention. | |
| **FOLLOW-UP:** Cardiology consultation, diabetes education, smoking cessation counseling | |
| --- | |
| Dr. Michael Chen, MD | |
| Emergency Medicine | |
| General Hospital | |
| Date: 06/10/2025, Time: 14:30 |