Admission Note for Chest Pain (ICU Management)

DATE: ............

CHIEF COMPLAINT: Chest pain x ............ minutes/hours/days

HISTORY OF PRESENT ILLNESS:

Site -
Onset -
Character -
Radiation -
Alleviating factors -
Time course -
Exacerbating factors -
Severity -
Nausea - , Vomiting - , SOB - , Sweating -
Similar chest pain (CP) before -

ER Tx given -

PND - , DOE - , Palpitations -
Fever/chills - , Cough - , Ankle swelling -
Claudication - , Headache - , Blackouts -
Recent travel -
Blurred vision - , Sore throat -
Abdominal pain - , Black/bloody stool -
Dysuria -

PAST MEDICAL HISTORY: (circle all that apply)
MI CAD CABG HTN CHF EF DM Hyperchol. Dilated CMP
Pacemaker

Stress test -
2D-Echo -
Catheterization -
When - Where -

Stroke CA PUD PVD DVT COPD Asthma Gallstones EGD (circle all that apply)
Colonoscopy

PAST SURGICAL HISTORY: (circle all that apply)
CABG Valve surgery
Cholecystectomy Hernia GSW Hysterectomy C-section

MEDICATIONS:

ALLERGY: NKDA

FMH: (circle all that apply)
CAD DM Stroke HTN CA

SOCIAL HISTORY: (circle all that apply)
Independent NH Lives w spouse son daughter
Alcohol - none heavy occasional last drink
Smoker - no
Illicit drugs - none cocaine heroin marijuana

REVIEW OF SYSTEMS: unremarkable apart from above symptoms

PHYSICAL EXAMINATION:
VITALS: Orthostatics-
SpO2 - Initial vitals -

GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD +JVD
LUNGS: CTA (B) crackles L R B wheezing
HEART: Clear S1S2, RRR irregular murmur S D /6 S3
ABDOMEN: Soft, NT, ND, +BS
Rectal exam:
EXTREMITIES: no edema +edema
PERIPHERAL VASCULAR: palpable nonpalpable Doppler
NEURO:
AAO x 3, CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B), SENSATION: nonfocal
DTR: ++, CEREBELLAR: non focal

LABS:

N= L= B= AG= LFT
Cardiac enzymes x 1 -
BNpep -
UA: Urine toxic screen -
CXR:
EKG:

A R A R E P Q R S T
D R I I E E

ASSESSMENT:
- CP due to
*CAD
*Muskuloskeletal CP - myofascial strain, costochondritis
*GERD
*Esophageal spasm
*Cocaine induced
*Pericarditis - unlikely
*Pneumonia - no infiltrate on CXR

CAD Risk factors: HTN Obesity PVD LDL FMH DM HDL Smoking Age (circle all that apply)

PLAN:
- Cardiac enzymes x 2 q 8 hr
- EKG now and in AM
- O2 to keep SpO2 higher than 92%
- ASA 325 mg PO QD
- Metoprolol 12.5 mg PO BID, hold for HR lower than 60 and SBP lower than 110
- Nitro IV drip start @ 6 mcg/min and titrate to chest pain, hold for SBP lower than 110
OR
- Nitro patch 0.4 mg TD daily
- Lovenox 1 mg/kg SQ Q 12 hr
OR
- Heparin 5000 U SQ BID
- Colace, Pepcid
- UA
- Urine toxic screen
- CBCD, BMP in AM
- Fasting lipids
- Morphine sulphate 2 mg IV q 2-4 hr PRN chest pain
- Tylenol 650 mg PO q 4-6 hr PRN headache
- Home meds (review and restart the appropriate meds)
- 2D Echo
- Cardiology consult

Signature:

Published: 02/11//2005

Updated: 04/01/2010