AI Scribe for Emergency Physicians

CHIEF COMPLAINT:
Chest pain

HPI:
56-year-old male with history of hypertension and hyperlipidemia presents with acute onset substernal chest pressure. Began 2 hours ago while watching TV. Describes pressure as 8/10 severity, radiating to left arm and jaw. Associated with diaphoresis and nausea. Denies shortness of breath, palpitations, or prior similar episodes. No recent illness, trauma, or exertion. Took 2 Tums at home without relief. Wife called 911.

Risk factors: HTN, HLD, family history (father MI age 58), former smoker (quit 5 years ago, 20 pack-year history)

Denies: recent cocaine use, prior cardiac history, PE risk factors

PAST MEDICAL HISTORY:
Hypertension, hyperlipidemia

MEDICATIONS:
Lisinopril 10mg daily, atorvastatin 40mg daily, aspirin 81mg daily

ALLERGIES: NKDA

SOCIAL HISTORY:
Former smoker (quit 5 years ago), occasional alcohol, no drug use

PHYSICAL EXAMINATION:
Vitals: BP 158/92, HR 94, RR 18, O2 sat 98% on RA, Temp 98.6°F
General: Anxious, diaphoretic, moderate distress
HEENT: No JVD
Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Normal S1/S2. Peripheral pulses 2+ and symmetric
Pulmonary: Clear to auscultation bilaterally, no rales or wheezes
Abdomen: Soft, non-tender, no organomegaly
Extremities: No edema, no calf tenderness
Neurologic: Alert and oriented x3, no focal deficits

DIAGNOSTIC STUDIES:
EKG (arrival, 14:32): Sinus rhythm, rate 94, normal axis, no acute ST-T changes, no prior EKG for comparison

Troponin I (14:40): 0.35 ng/mL (elevated, normal <0.04)

Labs:
- CBC: WBC 9.2, Hgb 14.5, Plt 225
- CMP: Na 138, K 4.1, Cl 102, CO2 24, BUN 18, Cr 1.0, Glucose 118
- PT/INR: 1.0/1.0

Chest X-ray: Normal cardiac silhouette, clear lung fields, no acute cardiopulmonary process

HEART Score: 5 (Moderate Risk - 12-17% risk of MACE)
- History: Moderately suspicious (1 point)
- EKG: Normal (0 points)
- Age: 56 years (1 point)
- Risk factors: 3 or more (2 points)
- Troponin: 2-3x normal limit (1 point)

MEDICAL DECISION MAKING:
56-year-old male presenting with concerning features for acute coronary syndrome including typical chest pain with arm/jaw radiation, diaphoresis, cardiac risk factors, and elevated troponin. HEART score 5 indicates moderate risk. EKG without STEMI but elevated troponin consistent with NSTEMI.

Differential diagnosis:
1. NSTEMI (most likely given troponin elevation and clinical presentation)
2. Unstable angina (less likely given troponin elevation)
3. Aortic dissection (low probability - equal pulses, no tearing pain)
4. Pulmonary embolism (low probability - no dyspnea, negative PERC)
5. Esophageal spasm (unlikely given troponin elevation)

Risk-benefit discussion:
Discussed admission for cardiac catheterization vs. observation. Given moderate-high risk features and positive troponin, admission to cardiology strongly recommended. Patient agrees to admission and cardiology consultation.

TREATMENT:
- Aspirin 325mg PO given
- Atorvastatin 80mg PO given
- Heparin drip initiated per ACS protocol
- Nitroglycerin 0.4mg SL x1 with partial relief
- Metoprolol 25mg PO given
- IV access x2
- Continuous cardiac monitoring
- Serial troponins ordered (q3h x2)

CONSULTATIONS:
Cardiology consulted - Dr. Johnson to evaluate, likely cardiac catheterization in AM

DISPOSITION:
ADMIT to Cardiology service
Admission diagnosis: NSTEMI
Condition: Stable
Full code status confirmed