Admission Note for Chest Pain (CP)

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 CP before -

ER Tx given -

PND -, DOE -, Palpitations -
Fever/chills - , Cough - , Ankle swelling -
Claudication - , Headache - , Blackouts -
Recent tavel -
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

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

Stroke CA PUD PVD DVT COPD Asthma Gallstones EGD
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
Sedentary -

REVIEW OF SYSTEMS: unremarkable apart from above symptoms

PHYSICAL EXAM:
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 -
CXR:
EKG:

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

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

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

PLAN:
- cardiac enzymes x 2 q 8 hr
- EKG now and in AM
- ASA
- Metoprolol 12.5 mg PO BID, hold for HR lower than 55 bpm
- O2 by NC to keep SpO2 greater than 92%
- UA
- Urine toxic screen
- CBCD, BMP in AM
- Fasting lipids
- Morphine 2 mg IV q 2-4 hr PRN chest pain
- Tylenol 650 mg PO q 4-6 hr PRN headache
- Home meds (check list)
- Heparin 5000 U SQ BID
- 2D Echo
- Cardiology consult

Signature:

Published: 02/11/2005
Updated: 03/08/2009