1. Patient profilepresenting complaint
2. History of presenting complaint
3. Past medical history
4. Past surgical history
5. Gynecological history
6. Family history
7. Sexual history
8. Social history
9. Drug history
10. Systems review
11. Examination
12. Summary

Patient profilepresenting complaint

I would like to
<introduce || present the case of>
<Mrs X>
a
<60 year old>
<steelworker>
from
<Dublin>
who was admitted
<through casualty || by her GP>
following a
<12 hour>
history of
<dyspnea and crushing chest pain>.

History of presenting complaint

In regards to the past medical historyshe last felt well
<6 months>
ago.

Then she began to notice
<a full description of old attacks of the complaint>
which was
<getting better || worse || constant>
over time.

Then
<today>
she
<pain>
came on
<suddenly>
while she was
<climbing a steep hill>.

She described the
<pain>
as a
<crushing pain>
<localized || diffuse> in the
<center of her chest>
of severity
<9/10>
which radiated
<down her left arm>.

The pain was
<constant || intermittent>
lasting for
<30 minutes>
and was made worse by
<attempting to walk>
but relieved by
<using her GTN spray>.

She came into
<hospital || her GP> at
<9:00 am on Mar 11th>
where she was given
<morphine>
which
<relieved the pain>
and administered a
<EKG>
test which showed
<findings of an MI>.
Patient was
<admitted to the cardiac ward || discharged>
and her current symptoms are
<improving || stable || yet to stabilize>.

If relevant to disease:
She has had
<2>
similar attacks in the past
<4 years>
with
<increasing || decreasing || similar>
severity and frequency.
<all || but none>
of which required admission to
<hospital || ICU>.

Past medical history

<Mrs X> has
<type II diabetes>
first diagnosed in
<1997>
which is controlled well
<glucophageand diet>.
She has
<No || a>
past history of
<MJ THREADSand details of any>.
and reports
<some depression || no depression>.

Past surgical history

A
<appendectomy>
was performed in
<1974>
with
<no complications || complications of...>
and
<no reaction || a reaction of...>
to the anesthetic.

Gynecological history

Menarache was at the age of
<13>.

If menopause:
and menopause was at age
<65>.
If no menopause:
Periods are
<regular || irregular>
with
<normal || heavy || intermittent>
bleeding.
Cyles are
<28 days>
periods last
<3 days>
and first day of her last period was
<March 3rd>.

She has
<3>
childrendelivered with
<no complications || complications of...>.

She had
<zero>
miscarriagesand
<no chance of || some chance of || is>
currently pregnant.

Family history

<No one || her sister...>
has experienced symptoms similar to her current complaint.

If any family members with similar symptoms:
<Details of dz in each...>

Her father passed away at
<65>
from
<a stroke>.

Her mother passed away at
<75>
from
<breast cancer>.

Her brother has
<severe angina>
first diagnosed at age
<40>.

Her children are
<in good health || dz's in children...>.

Extended family has
<nothing of note>.

Sexual history

If sexually active and relevant:
Last intercourse was
<March 6th>
with
<14>
total number of contactsin
<heterosexual || homosexual || bisexual>
relationshipsand
<no || number of...>
contacts with prostitutes.

Social history

<Mrs. X>
was born in
<Cork>
and currently resides in
<Dublin>.

Her present occupation for the last
<15 years>
is
<steelworker>
where she
<pours hot steel>
and there is
<no || number of...>
coworkers there with similar symptoms.

Previous occupations included
<butcher>
for
<3 years>
with
<no || number of...>
coworkers with similar symptoms that she knows of.

She lives in a
<single-floor>
<apartment>
on the
<1st floor>
with her
<husband and childrenaged 161821<who are all in good health>
and
<no pets || a pet...>

She
<manages well at home || is able to ... but needs help with ...>
with
<no community care needed || community care of meals on wheels 2 times aweek...>.

She maintains what she feels is a
<healthy || unhealthy>
though
<high in ... || low in...>
and exercises
<5>
times per week doing
<swimming>.

<Mrs. X>
currently
<does || doesn't>
smokeand
<has never smoked. || has smoked>
If has smoked:
<5>
<cigarettes || cigars || chewing tobacco>
for the last
<15 years>.

<Mrs. X>
currently
<does || doesn't>
drink alcoholand
<has never drank. || has drank>
If has drank:
<5>
<pints || vodkas || others...>
per
<week || month || year>
for the last
<15 years>.

She
<has || has not>
travelled abroad
to
<Singapore>
If immunizable complaint:
<was || was not>
immunized before leaving
and
<no new symptoms || symptoms of>
while there.

Drug history

The medications she is on at the moment are:
<drugdose>
for her
<disease>

<No>
supplementsalternative medicationsor recreational drugs.

<Is || is not>
taking
<OCP || HRT>.

<No allergies || allergic to thingsdrugsdyes>
wth the reaction of
<reaction>.

Systems review

A review of systems was non-contributory.

Examination

On examination

Summary

In summary
<Mrs. X>
is a
<60 year old>
woman with a
<12 hour>
history
of
<crushing substernal chest pain radiating down the L arm>
with positive risk factors of
<diabetes>
<menopause>
and
<high blood pressure>.

This is
<a classic case of || consistent with || my differential is>
<an acute MI>.

I would want to investigate with
<EKGenzyme levels>
to look for
<...>
and my management plan would consistent of conservative treatment of
<resteducation>
and pending a worsening of symptomsmore invasive procedures such as
<CABG>.

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