Templates


H&P

CC: Chest Pain

HPI: __ yr old pt with Hx of __ , present to ED complaining of 8/10, substernal, pressure like chest pain radiating to his left arm which started about _ hrs ago. Pain is exacerbated with exertion, relieved with rest. Pt reports similar symptoms on and off over the past few weeks which are now getting worse. Associated symptoms include nausea, vomiting and SOB. Denies lightheadedness, blurred vision, or fever.

PMH: DM, HTN, HLP, CAD, CVA, Tobacco abuse.

PSH:
CABG x _, Stent x 2.

FH: CAD, CVA, DM, Cancer

SOC: Lives with daughter, Current smoker (1 PPD x 30+ yrs), Denies Alcohol or IV Drug use.

ALLERGIES: NKDA

MEDS:   
1.
2.
3.
4.
5.
6.
7.
8.  

ROS: Review of all 14 systems is negative except for what is mentioned in HPI.

PHYSICAL EXAM:

Vitals: T= , BP= , P= , RR= .

CONSTITUTIONAL: VS x 3; normal habitus. 2/2.
[Well developed, well nourished, in NAD].
{frail, anxious, confused, unkept, elderly, in distress}

EYES: Conjunctiva clear; PERRLA; Discs Sharp. 3/3.
[EOMI]

ENT: Normal ext. ear & nose, External Auditory Canal & TMs clear; Nares Clear; OP Clear ?; Hearing intact; Dentition good. 6/6.
[No deformity/significant septal deviation; normal mucosa; moist mucus membranes; no erythema/exudates]

NECK: Supple; Trachea midline, No thyromegaly. 2/2

RESPIRATORY: CTAB; Normal effort; No dullness to percussion, no tactile fremitus. 4/4
{wheeze, crackles, crepitation}

CARDIO: RRR no MGR; PMI non-displaced, no carotid/aortic/femoral bruits, pedal pulses 2+, no edema. 7/7

CHEST/BREAST: Breast bilaterally symmetric w/o mass. 2/2

GI/ABD: No masses, tendreness, guarding or rebound. No HSM, No hernia.
{Murphy's sign- gall bladder.    Psoas / Rovsing/ Obturator sign - Appendicitis}

  1. RECTAL: normal ST, No masses or hemorrhoids, Guiac: neg. 5/5

GENITOURINARY:

  1. FEMALE: Normal ext. genitalia, urethra, vagina & bladder.
    Cervix: No dc, non-tender.
    Uterus: Retroverted w/ normal size, shape, consistency, non-tender,
    Adnexa: No masses, non-tender. 6/6.  
  2. MALE: ↓↓Testes no masses, non-tender, normal circumcised penis.
    Prostate: No masses, non-tender. 3/3

LYMPHATIC: No cervical, axillae, Inguinal or other LAD. 4/4

MSK: Normal gait/station, No clubbing/cyanosis. Joints/bones/muscles in extremities x4: Full ROM. Normal inspection & palpation, Normal stability, Normal strength & tone. 6/6.
[No hot, red or tender joints. No obvious deformaties, dislocaion or fracture. Full ROM of neck & back, No CVA tendrness].

INTEGUMENT: No rash or atypical lesion, No induration or nodules. 2/2
{? severe acne, rosacea, actinic keratosis, warts}

NEURO: CN 2-12 grossly intact. DTRs 2+ globally, sensation intact to light touch. 3/3
[No gross focal deficits, No nuchal rigidity]
{? weakness, rigidity, cogwheeling, hypersthesia, tremor, hyporeflexia, hyper-reflexia, abnormal gait, MENINGITIS: kernig sign, brudzinski's sign}.

PSYCH: A&O x 3, euthymic, appropriate affect, judgment & insight intact, recent & remote memory intact. 4/4
[Thought content appears normal, maintains good eye contact].
{? anxious, Agitaded, depressed. SIG EM CAPS}

 

Labs:
WBC Hgb Plt
Hct

Na Cl BUN Glu
K CO Cr

Urine Culture:
Bld Culture:


Imaging
:

 

Assessment /Plan:
  1. Chest Pain R/O ACS -- Oxygen, Morphine, Nitroglycerine, Aspirin, Lisnopril, Metoprolol, Simvastatin, Serial Cardiac enzymes and EKG, CXR, CBC, BMP, Mg, Phos, UA, TSH, HbA1c, Fasting lipid panel.
  2. Dehydration -- IV fluids
  3. Nausea/Vomiting - IV fluids, Zofran
  4. CAD -- continue cardio-protective medications (bb, ACEI, Aspirin, -statin)
  5. COPD -- Duoneb updraft
  6. DM --
  7. Hyperlipidemia -- Simvastatin
  8. Hypertension -- Lisinopril, Metoprolol
  9. GERD -- Pepcid 20mg PO bid.
  10. Prophylaxis -- Lovenox 1 mg/kg
  11. Pain/Fever -- Tylenol
  12. Tobacco Abuse -- counseled.




SOAP/Progress Note


S: 70 Yr old male admitted with chest pain is now much improved. He had an uneventful night. Slept good, no new complaints but is overwhelmed by his medical problems. Denies any cp, sob, n/v.

O
: Vitals T= , BP= , P = , R = , Sat =  on 2L via NC

PE:
Gen: NAD
HEENT: NC/AT, PERRLA, EOMI.
Pulm: CTAB no wheezes or crackles, equal expansion bilaterally
Cardio: RRR, no m/r/g
Abd: obese, soft, NT ND +BS no organomegaly
Ext: no c/c/e cap refill WNL, pulses 2+
Neuro: AAOx3, no focal deficits, CN ll - Xll intact

Labs
:
WBC Hgb Plt
Hct

Na Cl BUN Glu
K CO Cr

Urine Culture:
Bld Culture:

Imaging:



Meds:
1.
2.


Assessment /Plan:
  1. Chest Pain R/O ACS -- Oxygen, Morphine, Nitroglycerine, Aspirin, Lisnopril, Metoprolol, Simvastatin, Serial Cardiac enzymes and EKG, CXR, CBC, BMP, Mg, Phos, UA, TSH, HbA1c, Fasting lipid panel.
  2. Dehydration -- IV fluids
  3. Nausea/Vomiting - IV fluids, Zofran
  4. CAD -- continue cardio-protective medications (bb, ACEI, Aspirin, -statin)
  5. COPD -- Duoneb updraft
  6. DM --
  7. Hyperlipidemia -- Simvastatin
  8. Hypertension -- Lisinopril, Metoprolol
  9. GERD -- Pepcid 20mg PO bid.
  10. Prophylaxis -- Lovenox 1 mg/kg
  11. Pain/Fever -- Tylenol
  12. Tobacco Abuse -- counsel


 


 

Discharge Note

  • Disposition: Discharge to Home (OR) Transfer to Health South/Select/UAMS Little Rock
  • Discharge Diagnosis:
    1. Chest Pain, ACS ruled out with negative cardiac enzymes x3 - improved
    2. Hypertension
    3. GERD
       
  • Condition: Stable
     
  • Diet: Heart Healthy/ADA/Low Na diet
     
  • Activity: As Tolerated/Ad lib
     
  • Medications:

    1.  
  • Brief Hospital Course:
    • pt was admitted for chest pain... cardiac enzymes and EKG x3 were negative. Pt's symptoms improved significantly.
       
  • Procedures: (if any)
     
  • Consultations: (if any)
    Cardiology was consulted. Dr. Ali evaluated the pt and decided to do a stress test which was positive. CATH was performed which showed severe 2 vessel disease. Stents x2 were placed.
     
  • Significant studies/labs:
    CE (-) x3, Blood Cult, Urine culture
     
    WBC Hgb Plt
    Hct

     
    Na Cl BUN Glu
    K CO Cr

     
  • Instructions:
    1. Follow up with PCP in 1-2 weekss
    2. Take all medications as prescribed
    3. Outpatient 2D-Echo, Stress Test
    4. Copies to PCP (Dr. _____)