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**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 |