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Patient: John Smith
Age: 45
Date of Visit: April 22, 2024
Chief Complaint: Chest pain and shortness of breath.
History of Present Illness: Mr. Smith presents with a sudden onset of chest pain radiating to his left
arm, accompanied by shortness of breath. Symptoms began approximately 1 hour ago while he was
at rest. He denies any previous episodes. No alleviating or exacerbating factors reported.
Past Medical History: Hypertension, hyperlipidemia, and family history of coronary artery disease.
Medications: Lisinopril and simvastatin.
Allergies: None reported.
Social History: Non-smoker, occasional alcohol use, sedentary lifestyle.
Physical Examination:
- Vital Signs: BP 160/100 mmHg, HR 90 bpm, RR 20 breaths/min, Temp 98.6°F
- General: Appears uncomfortable, diaphoretic
- Cardiovascular: Regular rate and rhythm, no murmurs or gallops, diminished breath sounds in left
lower lung field
- Respiratory: Tachypneic, using accessory muscles
Assessment:
1. Acute coronary syndrome
2. Rule out myocardial infarction
Plan:
1. Administer oxygen at 2L/min via nasal cannula
2. Aspirin 325 mg chewed
3. Nitroglycerin sublingual 0.4 mg every 5 minutes x3 doses
4. EKG and cardiac enzymes
5. Morphine sulfate 2 mg IV for pain relief
6. Immediate transfer to cardiac care unit for further management and observation.